Persius/imr-appeals huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 63-year-old male enrollee has requested reimbursement for the prostate ablation performed on 10/24/17. The Health Insurer has denied this request indicating that the procedure at issue was not medically necessary for treatment of the enrollees prostate cancer. The physician reviewer found that in the peer-reviewed medical literature, Tay and colleagues concluded that, focused ultrasound is technically feasible for focal prostate ablation and appears to have a favorable early safety and functional profile. However, the authors cautioned that further clinical trials are necessary to establish oncologic efficacy. Moreover, there is a lack of current data demonstrating that HIFU provides improved long-term benefits over active surveillance in patients with low-grade and low-stage prostate cancer. Given the recommendations based on the current scientific evidence, the prostate ablation performed on 10/24/17 was not medically necessary for treatment of this patients prostate cancer. Based on the foregoing discussion, the procedure at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 38-year-old female with a history of hidradenitis suppurativa that has not responded adequately to multiple therapies, including topical and oral clindamycin, doxycycline, rifampin, cortisone injections, spironolactone, vitamin D and Humira. In a letter dated 11/30/20, the patientas provider reported that the patient was started on Otezla in combination with her Humira treatment in October of 2020 and has responded very well. The physician reviewer found that there is support for the requested medication in this clinical setting. Adalimumab (Humira) is the only U.S. Food and Drug Administration (FDA) approved therapy for hidradenitis suppurativa (HS), which the patient is currently taking. She has a failed a number of other commonly used drugs, many of which are listed in the North American HS treatment guidelines. Of note, apremilast (Otezla) is not listed within these guidelines published in 2019. However, there was one very small randomized controlled trial and also an open-label observational study evaluating Otezla as a treatment for HS, which both showed modest efficacy after 16-24 weeks of therapy. Given the modest benefit reported for Otezla in the literature, it would be medically reasonable to
continue this treatment for another two months to determine if there is any clinical benefit from the drug and reassess the need thereafter. Therefore, Otezla is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 38-year-old female has requested reimbursement for laboratory testing performed on 7/06/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who had a history of recurrent pregnancy loss. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  The records indicate that the patient had a history of two first trimester miscarriages and had the diagnosis of recurrent miscarriage.  The etiologies for recurrent miscarriage may include chromosomal, uterine structural, ovulatory, thrombophilias and immune factors or combinations of these factors. The obstetric complications most often associated with thrombophilias are miscarriage, stillbirth, and abruption.  The American Society for Reproductive Medicine, in its Practice Committee Opinion, notes that screening for inherited thrombophilias may be appropriate when a patient has a personal history of venous thromboembolism in the setting of a non-recurrent risk factor (such as surgery) or a first-degree relative with a known or suspected high-risk thrombophilia.  There is no evidence in the medical record that the patient has a personal or family history of a thrombophilia. Therefore, there is no support within the standard of care for inherited thrombophilia testing. In addition, the medical evidence indicates that there is no significant association between MTHFR and recurrent miscarriage.  Therefore, MTHFR testing is not within the standard of care.  In sum, laboratory testing performed on 7/06/15 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: Upheld

Summary Reviewer 3

A 56-year-old female enrollee has requested authorization and coverage for biliopancreatic bypass with duodenal switch (CPT code 43845). The Health Insurer has denied this request indicating that requested procedure is considered investigational for treatment of the enrollee, who has a history of morbid obesity and type 2 diabetes. The physician reviewer found that there is support in the medical literature for the requested procedure in this clinical setting. Biliopancreatic bypass with duodenal switch is documented to be superior to medical management for treatment of weight loss. Duodenal switch is also associated with higher rates of diabetes remission, but there are some studies which link this procedure to higher rates of protein malnutrition. If the patient and her provider are prepared to deal with the potential outcomes that comes with this procedure, then biliopancreatic bypass with duodenal switch is an appropriate treatment option.   As such, biliopancreatic bypass with duodenal switch (CPT code 43845) is likely to be more effective than the medical management options for treatment of this patients medical condition. Based upon the information set forth above, the requested procedure is likely to be more beneficial for treatment 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 

A 62-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 3/05/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. There is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. This test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Therefore, DecisionDx-Melanoma testing performed on 3/05/19 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 53-year-old female enrollee has requested reimbursement for gene testing performed on 11/15/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma.The physician reviewer found that the melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha.  The data on DecisionDx-Melanoma test has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, gene testing performed on 11/15/16 was not likely to have been more effective than other modalities for 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 42-year-old female who has been diagnosed with myasthenia gravis. Per the submitted documentation, this causes difficulty with breathing and swallowing.  The physician reviewer found that the 2012 American Academy of Neurology guidelines for intravenous immunoglobulin in the treatment of neuromuscular disorders recommends that IVIG should be considered in the treatment of myasthenia gravis. This recommendation was based on studies involving primarily moderately or severely affected patients. A retrospective study by Sorgun and colleagues investigated thirteen patients who had displayed an inadequate clinical response to immunosuppressive treatments, or who were not appropriate for immunosuppressive treatment due to the age factor and thus were given regular IVIG therapy. The number and severity of the attacks were decreased in all patients. The authors concluded, IVIG can produce repeated beneficial effects in patients with myasthenia gravis and may be useful as an adjunct in the management of myasthenia gravis. IVIG has minimal adverse effects and ability to reduce corticosteroid dose. In this case, the patient has severe myasthenia gravis that affects her breathing and swallowing.  She had an inadequate clinical response to other immunosuppressive treatments and has osteoporosis, which could be exacerbated by the use of corticosteroids. Treatment with weekly IVIG has improved her symptoms. Based on the studies noted above, IVIG is a valid modality in this patient because it has decreased the number and severity of exacerbations and has allowed a decrease in her corticosteroid dosage. For these reasons, IVIG 500 mg twice per week is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 21-year-old male enrollee has requested authorization and coverage for Consentyx Pen 150 mg. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees severe plaque psoriasis.  The physician reviewer found that Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation (Marji, et al). Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor (TNF) biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus (Patel, et al). Cosentyx selectively binds to IL-17A, inhibiting its interaction with the receptor, thus inhibiting its downstream effects on keratinocytes in plaque psoriasis (Reich, et al). In addition, Cosentyx is approved by the U.S. Food and Drug Administration (FDA) for treatments of such patients (Gohil). The patient has severe, disseminated, chronic plaque psoriasis that requires systemic treatment. He has failed treatment with standard therapies including Dovonex, Taclonex, and methotrexate. Thus, the requested Cosentyx Pen 150 mg is medically necessary for treatment of this patients psoriasis. Consistent with these findings, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 62-year-old female has requested reimbursement gene testing performed on 11/01/15. 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 the patient with ovarian cancer received chemotherapy but debulking surgery revealed residual tumor. This suggests marked chemotherapy resistance. Her providers submitted her tumor specimen for mutational analyses to identify other therapies.  Von Hoff and colleagues performed a study of 86 patients where the progression-free survival on regimen selected by molecular profiling was compared to progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has very significant results for patients with stage IV tumors.  In sum, the gene testing performed on 11/01/15 was 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 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 15-year-old enrollee has requested reimbursement for adolescent mental health residential treatment provided from 6/02/18 through 8/04/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in terms of risk of harm, the records support a score of 2. The medical records indicate that the patient was not actively suicidal. He did not engage in any self-harm behaviors but did have a reported history of suicidal ideation. With regards to functional status, the records support a score of 3. The patient has had issues with level of functioning due to mental illness in the past and relationship problems, but overall showed appropriate daily functioning while in treatment, including cooperation in treatment and intact activities of daily living. In terms of comorbidity, the records support a score of 1. The patient did not have active medical problems or substance use that affected his primary psychiatric issues. With regards to level of stress of the recovery environment, the records support a score of 2. There is no indication of an unsafe home environment. In terms of level of support of the recovery environment, the records support a score of 2. The patients family was actively involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 3. It appears that the patient was stable while in the residential treatment center. In terms of acceptance and engagement of the child, the records support a score of 2. The patient actively participated in therapy. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Therefore, the patient has a composite score of 17. This score correlates with intensive outpatient services. Therefore, adolescent mental health residential treatment provided from 6/02/18 through 8/04/18 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer

The patient is a 52-year-old female who presented with a well-defined nodular mass at the left acromioclavicular joint. The provider ordered magnetic resonance imaging (MRI) of the chest for evaluation. The patient had no history of trauma, fever or known malignancy. The patient has requested reimbursement for the MRI of the chest without contrast provided on 11/15/17. The Health Insurer has denied this request indicating that the diagnostic procedure was not medically necessary. The acromioclavicular joint is a common location for prominent physical findings and is usually due to a hypertrophic osteophyte or old healed fracture. Plain x-rays are typically considered sufficient to evaluate such findings if present. Moreover, if these findings were demonstrated on plain x-rays, this would have negated the need for MRI. Thus, without the initial radiograph as a guide for further imaging, the MRI of the chest without contrast provided on 11/15/17 was not medically necessary for evaluation of this patients medical condition.  Based on the foregoing, the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 53-year-old female enrollee has requested reimbursement for a sleep study performed on 12/19/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees insomnia. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. The patient presented with obesity, snoring and insomnia. Sleep onset insomnia is not an indication for a sleep study. Patients with sleep onset insomnia have a long sleep latency and patients with clinically significant sleep apnea have a short sleep latency. Moreover, the patients Epworth Sleepiness Scale score was normal. Thus, the patient did not have hypersomnia. Hypersomnia is the cornerstone for a diagnosis of sleep apnea. In addition, there was no documentation of witnessed sleep apnea or awakening gasping for breath. Furthermore, the patient did not have sleep apnea per sleep study. Based on the medical records submitted and the peer-reviewed literature, the sleep study performed on 12/19/14 was not medically necessary for evaluation of the patients medical condition. For the reasons provided, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

The patient is a 59-year-old female who was diagnosed with recurrent leiomyosarcoma of the uterus. A sample tissue was sent for genetic testing. The patient has requested reimbursement for the FoundationOne test performed on 11/14/16. The Health Insurer denied this request and reported that the services at issue were investigational for evaluation of this patients medical condition. To demonstrate the clinical utility of panel genetic testing, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. At this time, there is a lack of such trials, which have been published. Currently recognized and accepted molecular evaluation and classification of soft tissue sarcoma (STS) include standard histological evaluation. Effective therapy for STS, including classification, is well summarized in the National Comprehensive Cancer Network (NCCN) guidelines. There is a lack of support in the literature for broad genomic panel testing. The available literature on clinical utility consists of a small number of uncontrolled studies and nonrandomized controlled trials that use imperfect comparators. This evidence is not sufficient to make conclusions as to the clinical utility of broad genetic testing. In addition, there is potential for harm if ineffective therapy is given based on test results because there may be adverse effects of therapy in the absence of a benefit. As a result, the use of expanded mutation panel testing for targeted treatment in cancer is considered unproven,  For these reasons, the FoundationOne test performed on 11/14/16 was not likely to have been of greater benefit than other treatment modalities for evaluating this patient.   Therefore, for the reasons stated 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 3

A 61-year-old female enrollee has requested authorization and coverage for positron emission tomography (PET) scan. The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees lung cancer. The physician reviewer found that small cell lung carcinoma (SCLC) is an aggressive pulmonary neuroendocrine neoplasm. Typical treatment for limited stage SCLC typically involves a combination of chemotherapy and radiation therapy, as in this case. PET/CT combines functional/metabolic as well as anatomic information and is utilized in the setting of SCLC to guide initial treatment strategy or modify treatment. The National Comprehensive Cancer Network (NCCN) recommends post-treatment surveillance of non-surgical lung cancer with chest CT approximately every six months or more frequently in some cases. PET-CT is not routinely recommended in cases where there is no radiographic sign of disease. However, the guidelines state that it may be useful in assessing abnormalities seen on CT scan which are indeterminate, and may represent post-treatment changes or recurrence. In this case, the results of the patients most recent CT scan in May 2018 were suspicious for disease recurrence, although nonspecific. As stated in the NCCN guidelines, PET is the recommended next test to clarify inconclusive CT results and determine if biopsy is necessary. As biopsy is risky in this patient due to severe underlying lung disease, it should only be performed if absolutely necessary. Thus, the requested PET scan is likely to be more efficacious than other modalities for evaluating this patient. Based upon the information set forth above, the requested services are 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: Upheld

Summary Reviewer 3


A 30-year-old female enrollee has requested reimbursement for the Anser ADA serological markers performed on 8/21/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that the use of biologics such as Humira in Crohns disease places patients at risk for potential serious side effects. This is important when a patient loses response to Humira, which requires increasing the dose. In this case, there is concern as the disease is quite advanced and the patient had already failed several regimes. Therapeutic levels and lack of antibodies may point the treating provider toward a different medication versus another etiology. Thus, testing for antibodies identifies the subset of patients who will benefit from an increased dose. Moreover, checking for antibodies helps optimize clinical response by helping achieve a more optimal drug concentration. All told, the Anser ADA serological markers performed on 8/21/15 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.