Persius/imr-appeals huggingface dataset:
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 62-year-old male enrollee has requested reimbursement for services (Foundation One testing) performed on 2/07/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. The prognosis of patients with recurrent or metastatic head and neck squamous cell cancer is generally poor. Treatment options include single-agent therapy and combination regimens using either conventional cytotoxic chemotherapy and/or molecularly targeted agents combined with best supportive care. Conventional cytotoxic drugs, checkpoint inhibitor immunotherapy, and molecularly targeted compounds have activity in metastatic and recurrent head and neck cancer. The National Comprehensive Cancer Network indicates that the best management of any patient with cancer is in a clinical trial. Molecular profiling can help identify available therapies (such as immunotherapy) or potential for clinical trials. Therefore, services (Foundation One testing) performed on 2/07/19 were likely to have been more beneficial than other standard methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


The parent of a 14-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 10/7/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the medical literature indicates that measurement of infliximab levels and anti-infliximab (anti-chimeric) antibodies produces actionable data (Afif, et al; Yanai and Hanauer).  Change of dose or drug based on these results improves response to treatment, as measured by clinical response.  The study by Hoekman and colleagues demonstrates that lower infliximab troughs are associated with elevated markers of mucosal inflammation in children. Paul and colleagues demonstrate prospectively that an increase in infliximab levels leads to a decrease in those same markers. Moreover, infliximab levels and antibodies allow the providers to adjust or change biologic therapy with some objective determinants. The utility of this approach is indicated in the article by Huang and colleagues who demonstrate that knowledge of infliximab trough levels frequently leads to a change in treatment course. An alternative is to sequentially increase dose and decrease dosing frequency of infliximab, then empirically change to another medication, typically adalimumab. However, this clinical approach can be lengthy and prolong a patients symptoms as well as the likelihood of an intercurrent hospital admission. In sum, the medical literature supports the use of infliximab levels and antibody measurements in the setting of inadequate clinical response to treatment, as well as for monitoring effectiveness of dose escalation. Therefore, the Prometheus Anser IFX testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3 
 
The parent of a six-year-old male insured has requested reimbursement for Coronavirus COVID-
19 (SARS-CoV-2) respiratory panel performed on 11/8/22. The Health Plan has denied this request 
indicating that the requested services are considered investigational for evaluation of the insureds 
respiratory illness with concern for SARS-CoV-2 infection. The physician reviewer found that on 
review of the current medical literature, the BioFire 2.1 Respiratory Panel was appropriate for use 
in this patients clinical setting. The accurate diagnosis of COVID is essential for infection control 
and prevention. When a patients household has immunosuppressed or elderly patients, an accurate 
diagnosis is needed for quarantine. Also, this information is helpful to monitor for multisystem 
inflammatory syndrome (MIS-C), which is a potential complication of COVID in pediatric patients 
that can manifest four to six weeks after the initial COVID infection (Kabeerdoss, et al.). Proper 
diagnosis  helps  create  a  timeline  for  monitoring  pediatric  patients  for  the  constellation  of 
symptoms associated with MIS-C. For these reasons, the Coronavirus COVID-19 (SARS-CoV-2) 
respiratory panel performed on 11/8/22 was likely to be more beneficial for evaluation of the 
patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 59-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/9/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination. The physician reviewer found that the medical literature supports breast tomosynthesis in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, the literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis performed on 8/9/16 was likely to have been superior to other methods of evaluating this patient. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 71-year-old female with osteoporosis. Per the records, she has tried alendronate twice. The first time she tried alendronate was in 2010, causing neck pain and headaches. The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting. In this case, the patient has osteoporosis, and the recommendation is to treat it in order to decrease the patients risk of fracture and subsequent morbidity. Prolia (denosumab) has been approved by the U.S. Food and Drug Administration for the treatment of osteoporosis in postmenopausal women at high risk of fracture. Denosumab has been approved for first-line therapy for osteoporosis and prevention of fractures. In this case, the patient has tried an oral bisphosphonate (alendronate) twice, which in both instances was associated to systemic side effect. Therefore, J0897 (Prolia, 60 mg/ml syringe, 60 mg injected every six months for one year) is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 47-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the requested services in this patients case. He has an apnea-hypopnea index of 21.1 and is unable to tolerate continuous positive airway pressure therapy. This patient meets clinical criteria for consideration of surgical management of his obstructive sleep apnea symptoms. Clinical studies of the use of hypoglossal nerve stimulation suggest that patients with a body mass index less than 32 benefit from this device. This patient meets this criteria, as his body mass index is 28.19. Thus, hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System is likely to be more efficacious than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 45-year-old female enrollee has requested reimbursement and prospective authorization and coverage for Gamunex-C from 7/01/21 forward. The Health Insurer has denied this request and reported that the medication at issue was and is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the polyneuropathies involve widespread damage to the bodyas peripheral nerves. Small fiber polyneuropathy (SFPN), also known as small fiber neuropathy, refers to those polyneuropathies that preferentially affect peripheral neurons with the thinnest axons. Small fiber neurons multifunctionality explains why SFPN increases risk of multiple symptoms. The most common are chronic widespread pain and/or itch, postural hypotension and/or tachycardia (POTS), nausea, constipation and/or diarrhea, disordered sweating, followed by urological and sexual dysfunction. Many studies have shown that autoimmunity and inflammation play a great role in SFPN. Treatments for these involve high dose steroids, IVIG or plasma exchange. Steroids carry significant side effects. Therefore, over the years, IVIG has been assuming a more important role. Cessation of the IVIG treatment in this patient could be detrimental to her health and quality of life. Therefore, Gamunex-C from 7/01/21 forward was and is likely to be more beneficial for the treatment of this patient than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 56-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/29/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, the original mammogram performed on 7/21/15 was done as a screening study, so that it is not unreasonable for the images to have been interpreted after the patient left the facility.  To recall the patient for additional images once a suspicious abnormality is detected is typical and appropriate.  However, it is not reasonable to repeat another tomosynthesis after only eight days.  While the first breast tomosynthesis was warranted due to the heterogeneously dense nature of her breasts and the asymmetry, the records do not establish the need for the second breast tomosynthesis.  Therefore, the breast tomosynthesis performed on 7/29/15 was not likely to have been more effective than other methods of evaluation.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 41-year-old female enrollee has requested reimbursement for a dopamine transporter single-photon emission computed tomography (DAT-SPECT) scan performed on 9/17/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of tremor. The physician reviewer found that DAT-SPECT scanning has high sensitivity and specificity relative to differentiation between Parkinsons disease and other forms of tremor.  However, it does not well correlate with treatment options which would depend upon the results of this testing.  The diagnosis of essential tremor had been well-established in this case based on the response to propranolol with very little documented evidence of a parkinsonian syndrome.  Accordingly, the DAT-SPECT scan performed on 9/17/15 was not likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 60-year-old male enrollee has requested authorization and coverage for nerve stimulator implant. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient has failed continuous positive airway pressure (CPAP) therapy. He has attempted to use an oral appliance, with limited success. The medical evidence supports the requested services for patients who have failed CPAP therapy. Withrow and colleagues noted that apnea-hypopnea index (AHI) reduction and therapy usage were found to be somewhat higher among patients who were 65 years of age or older, and surgical complications with upper airway stimulation were low. In sum, the requested nerve stimulator implant is likely to be more effective than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3 
 
A 58-year-old male enrollee has requested authorization and coverage for proton beam radiation 
therapy (PBT). The Health Insurer has denied this request and reported that the requested service is 
investigational for the treatment of the enrollees locally advanced esophagus cancer. The physician 
reviewer found that PBT is likely to be more beneficial for treatment of the patients condition than any 
available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

The parent of a 14-year-old female enrollee has requested reimbursement for subtalar arthroereisis provided on 12/11/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral moderate-to-severe pes planus. The physician reviewer found that review of the current peer-reviewed medical literature does not provide adequate support for the safety and effectiveness of subtalar arthroereisis for the treatment of bilateral flatfoot. Moreover, there is a lack of indication for this procedure in this patients records. As this procedure has not been proven in the medical literature as safe and effective for the treatment of this patients medical condition, the subtalar arthroereisis performed on 12/11/14 was not likely to have been more beneficial for treatment of this patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 34-year-old female enrollee has requested authorization and coverage for BRCA testing. The Health Insurer has denied this request indicating that the requested testing is considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found the requested testing is likely to be more effective for this patient than other available treatment options. In this case, the patient meets the National Comprehensive Cancer Network (NCCN) guidelines as she has a second degree relative diagnosed with breast cancer at age 45. In addition, she has no living affected relatives who can be tested. Therefore, BRCA genetic testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a 17-year-old female enrollee has reimbursement for psychiatric residential treatment from 10/06/18 through 10/20/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining necessary level of care for children. With regards to risk of harm, the records support a score of 1. The medical records indicate that the patient was not actively suicidal anytime during the disputed timeframe at the residential treatment center. In terms of functional status, the records support a score of 2. The patient has had some issues with level of function, but the progress notes indicate significant improvement after a period of deterioration. With regards to comorbidity, the records support a score of 2. The patient did not have active medical problems, and her psychiatric symptoms were minimal and under control. In terms of level of stress of the recovery environment, the records support a score of 2. The records noted a positive recovery environment and a stable housing situation. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment. In terms of resiliency and treatment history, the records support a score of 3. The records documented good response to a short period in the residential treatment center prior to the disputed dates of service. With regards to acceptance and engagement of the patient, the records support a score of 3. The patient participated in therapy actively, and her insight and judgment were noted to be good throughout treatment. In terms of acceptance and engagement of the parent, the records supported a score of 2. The parents worked actively and constructively with clinicians. Thus, the patient has a composite score of 17. This score correlates intensive outpatient services. In sum, psychiatric residential treatment from 10/06/18 through 10/20/18 was not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 60-year-old female enrollee has requested authorization and coverage for Botox. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees chronic migraine headaches The physician reviewer found that the submitted documentation fails to support the superior efficacy of the requested medication in this clinical setting. The available medical records indicate treatment with Botox but do not demonstrate or quantitate the specific degree of any benefit. The records provided do not specifically delineate or quantitate the frequency of the headaches in terms of days per month. The records describe a duration of two and a half months but does not describe any specific headache frequency decrease, headache intensity decrease or otherwise demonstrate any analgesic use reduction.  There was no presentation of a headache diary. Moreover, there were no other mechanism demonstrating headaches lasting four or more hours per day within 15 days or more per month.  As such, the effectiveness of Botox for treatment of this patient has not been demonstrated. Therefore, for the reasons stated above, the requested medication is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.  AND FINDINGS]
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 24-year-old female enrollee has requested reimbursement for 83993 (fecal calprotectin) provided on 1/30/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of diarrhea. The physician reviewer found that Fecal calprotectin is often ordered to determine whether inflammation (disease activity), such as inflammatory bowel disease, is present as a cause for gastrointestinal symptoms such as diarrhea. A meta-analysis by Van Rheenen and colleagues found that up to 11% of adults with inflammatory bowel disease may be misclassified as having noninflammatory disease, such as irritable bowel syndrome. As a rule-out test, this is not sufficient. The use of calprotectin to diagnose change in bowel habits has not been subsequently accepted. The impact of this testing on management and its appropriateness in guiding therapy decisions in patients with unexplained diarrhea has not been demonstrated. The findings can be redundant with standard methods of diagnosis, such as colonoscopy or sigmoidoscopy, or other serum markers of inflammation. Guidelines on the diagnosis and management of diarrhea do not recommend calprotectin as part of the investigation. Furthermore, clinical studies do not support a standardized action, such as empiric use of antibiotics or empiric therapy for inflammatory bowel disease, for a positive result. For these reasons, 83993 (fecal calprotectin) provided on 1/30/18 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 64-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 2/1/16.  The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it brings to radiologists interpreting mammograms especially in patients with extremely or heterogeneously dense tissue such as the patient in this case. Tomosynthesis allows radiologists to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of tomosynthesis to the usual two-dimensional imaging protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.