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

Summary Reviewer 2

A 35-year-old female enrollee has requested reimbursement for homocysteine testing provided on 6/05/18 and 7/16/18. 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 miscarriage. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The American College of Obstetricians and Gynecologists noted that testing for inherited thrombophilias in women who have experienced recurrent fetal loss or placental abruption is not recommended because it is unclear if anticoagulation therapy reduces recurrence. Although there may be an association in these cases, there is insufficient clinical evidence that antepartum prophylaxis with unfractionated heparin or low molecular weight heparin prevents recurrence in these patients. The only superseding issue would be if the patient had a personal history of venous thromboembolism or a first-degree relative with a history of high-risk thrombophilia. No such history is presented in this case. In sum, homocysteine testing provided on 6/05/18 and 7/16/18 was not likely to have been more effective 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 2

A 51-year-old female enrollee has requested reimbursement for the MammaPrint genetic test provided on 2/3/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees left breast carcinoma. The physician reviewer found that in the peer-reviewed medical literature, there is inadequate data demonstrating that a high risk MammaPrint result is a reliable indication for chemotherapy. Further, there is currently a lack of data to support using MammaPrint testing in patients with intermediate OncotypeDX score. Although Cardoso and colleagues reported that MammaPrint has been shown to improve prediction of clinical outcome in women with early-stage breast cancer, this patient already underwent genetic testing with OncotypeDX and was noted to have lymphovascular invasion. Thus, additional genetic testing was not needed for decision making regarding adjuvant chemotherapy. All told, the MammaPrint genetic test provided on 2/3/16 was not 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 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 1
A 57-year-old female requested reimbursement for magnetic resonance imaging (MRI) provided on 9/2/16.The Health Insurer has denied this request and reported that the service at issue was  considered investigational for evaluation of the enrollee who has a history of breast cysts. The physician reviewer found that there is support in the medical literature for the service at issue in this clinical setting. The positive family history, the dense tissue on mammography, and the presence of implants all limit the accuracy of mammography in this patient. MRI is the most sensitive means with which to screen for breast cancer and most patients with this risk level will undergo alternating MRI and mammography every six months. The use of MRI in this clinical setting has been advocated by many breast imaging organizations as well as the American Cancer Society. For these reasons, MRI performed on 9/2/16 was likely to be superior to other modalities available for the evaluation of 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: Experimental
Decision: Overturned

Summary Reviewer 1

The patient is a 64-year-old female with a history of severe sleep apnea. The records document an apnea-hypopnea index of 43.0 per a sleep study dated 10/12/17. She had no central apneas. She has tried a continuous positive airway pressure (CPAP) device, but has not been able to tolerate it. She is status post septoplasty and turbinate reduction, without improvement. The patient has requested coverage for an implanted nerve stimulator. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of this patient.  This patient has severe obstructive sleep apnea and has not been able to tolerate the CPAP device. She has undergone septoplasty and turbinate reduction, which has not improved her condition. The Inspire device is medically appropriate in this clinical setting. Her body mass index is below 32. This patient is a candidate for the Inspire device. Therefore, the implanted nerve stimulator is likely to be more efficacious than other treatment options in this patients case. Based upon the information set forth above, the requested device 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: Experimental
Decision: Upheld

Summary Reviewer 2

A 43-year-old female enrollee has requested reimbursement for the blood testing provided on 1/17/17. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cardiovascular risk. The physician reviewer found that the use of the advanced lipoprotein testing with measurement of low density lipoprotein (LDL) cholesterol particle numbers remains controversial. While some providers have advocated for its use, the American College of Cardiology (ACC) guidelines do not support its use, recommending instead standard risk assessment protocols and standard lipid profile testing (Stone, et al). The ACC moved away from specific target goals of LDL in their most recent guidelines, based on review of outcome studies. Lloyd-Jones and colleagues provided an expert consensus update from the ACC and it does not mention the use of advanced lipid testing. Overall, the guidelines do not establish a strong recommendation for use of the advanced lipid profiles at this time. Thus, the blood testing provided on 1/17/17 was not 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 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


The parent of a 13-year-old female enrollee has requested reimbursement for homocysteine testing performed on 12/31/15. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees behavioral health condition. The physician reviewer found the homocysteine testing is not a standard therapy recognized for treatment of ADHD. While a study by Karababa and colleagues was aimed at evaluating the homocysteine levels and oxidative stress parameter in patients with ADHD, that study only involved 32 adult ADHD patients. Moreover, the study concluded that oxidative balance is not impaired in adult ADHD patients and homocysteine levels were found to be lower (Karababa et al).  Due to the lack of peer-reviewed literature to support the use of this test in evaluating and treating the patients ADHD symptoms, the test at issue was not likely to be more beneficial than available standard therapies. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 52-year-old male enrollee has requested reimbursement for a wearable cardioverter defibrillator provided on 1/24/19. The Health Insurer has denied this request indicating that the device at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer found that documented high risk of sudden cardiac death in patients with severe left ventricular dysfunction has led to the recommendation of implantable cardioverter defibrillators in this group of patients. Current data from multiple trials and registries have advocated the use of a wearable cardioverter defibrillator after an initial diagnosis of severe left ventricular dysfunction with an ejection fraction of less than or equal to 35%. This patients ejection fraction was 25 to 30%. The recommended timing of a wearable cardioverter defibrillator placement based on guidelines from the American College of Cardiology/American Heart Association and the Heart Rhythm Society is within 40 days of an acute myocardial infarction or within 90 days of an initial diagnosis of congestive heart failure with a low ejection fraction. Therefore, the placement of the patients wearable cardioverter defibrillator on 1/24/19 falls within accepted guidelines. Thus, the wearable cardioverter defibrillator provided on 1/24/19 was likely to have been more effective than other treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


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 the medical evidence does not support the superior effectiveness of the services at issue in this patients case.  This is a situation where there were a number of possible reasons for this patients miscarriages, including her advanced age, her hypothyroidism, and the septate uterus.  In fact, her age and likely a chromosomal issue accounted for the early first trimester loss, and the septum was likely the etiology of the second trimester loss.  As part of her work-up the provider ordered a thrombophilia panel.  The reason put forth was that this might be useful if the assessment for a uterine anomaly did not reveal a problem.  However, current medical literature does not support such screening in a patient with a prior first and second trimester loss, such as in this case.  In sum, the information from the panel was not likely to elucidate the cause of her pregnancy losses, nor would it change her future treatment.  There were other diagnoses that likely contributed to the pregnancy losses.  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: Medical Necessity
Decision: Overturned

Summary Reviewer 




A 24-year-old female enrollee has requested authorization and coverage for molecular pathology laboratory testing. The Health Insurer has denied this request indicating that the requested testing is not medically necessary for evaluation of the enrollees autism spectrum disorder (ASD), developmental delays and epilepsy. The physician reviewer found that according to the American College of Medical Genetics and Genomics (ACMG), whole genome/exome sequencing should be considered in the clinical diagnostic assessment of patients with a phenotype that is strongly associated with a genetic etiology. In this case, several first tier evaluations have been conducted and were non-diagnostic. Given the complex nature of the patients phenotype, physical presence of cafe au lait macules, and a concerning family history autism, whole exome/genome testing is the next logical step and is consistent with the standards of practice within the field of genetics. The combination of chromosomal microarray and whole exome/genome testing greatly increases the likelihood of a unifying diagnosis (Tammimies, et al). Given these findings, the requested molecular pathology laboratory testing is medically necessary for evaluation of this patients medical condition. Based on the foregoing discussion, the requested testing is medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 51-year-old male enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation from 8/08/16 forward.  The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  It is uncertain if this patients current symptoms are due to a substance induced mood disorder.  One of his previous depressive episodes was likely brought on by methamphetamine abuse.  There was no documentation of a negative urine drug screen.  There is a lack of robust studies showing improvement in patients with major depressive disorder and comorbid posttraumatic stress disorder.  Flory and Yehuda reported that patients with posttraumatic stress disorder and comorbid major depressive disorder have a high likelihood for poor response to treatment.  The treatment recommendation for major depressive disorder with comorbid posttraumatic stress disorder is trauma-based psychotherapy.  All told, transcranial magnetic stimulation from 8/08/16 forward was not and is not medically indicated for the treatment of this patient.  Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 8/30/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas melanoma. The physician reviewer found that 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 to 1.0 mm. Metastases to regional lymph nodes may be amenable to excision but they suggest 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 testing 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. All told, DecisionDx-Melanoma testing provided on 8/30/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 12-year-old male enrollee has requested reimbursement for neuropsychological testing performed on 1/18/17. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees behavioral health issues. The physician reviewer found that Neuropsychological testing was recommended in this case to aid with determining the patients diagnosis and clarifying depression. Per the American Psychiatric Association (APA), psychological and neuropsychological tests are not mandatory for the diagnosis of ADHD, but should be performed if the patients history suggests low general cognitive ability. The current standard of care for diagnosis of ADHD is through full clinical evaluation. In addition, Wolraich and colleagues noted that to make a diagnosis of ADHD, the primary care clinician should determine that Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria have been met. This patients records do not indicate that the patient had a low general cognitive ability or any other neurological deficits that would require further and more complex evaluation. This patient had a history of tics and memory problems. Tics are more common in children with anxiety and ADHD but do not necessitate any form of neuropsychological testing. The patients memory problems can be explained by a diagnosis of ADHD. The criteria listed in the patients intake assessment are consistent with the diagnostic criteria for ADHD and additional testing was therefore not indicated. In summary, the neuropsychological testing performed on 1/18/17 was not medically necessary for evaluation of this patients medical condition. Based on the foregoing, the testing at issue was not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 54-year-old female enrollee has requested authorization and coverage for positron emission tomography/computed tomography (PET/CT). The Health Insurer has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees left breast carcinoma. The physician reviewer found that PET scanning involves a determination of the uptake of radioactive glucose in bodily tissues. There is abnormally increased uptake in a variety of tissues including cancer and inflammation as well as post-operative healing. There is adequate medical literature supporting the role of PET/CT in this clinical setting. This patient is at high risk for recurrence of cancer and has not been able to take hormonal therapy. Since the area of concern has been noted to be too small to appropriately biopsy, the requested PET/CT scan is likely to be more beneficial for evaluation and treatment of this patients breast cancer than any other available modality. Based upon the information set forth above, I have determined the requested diagnostic procedure 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: Experimental
Decision: Upheld

Summary Reviewer 3


A 50-year-old female enrollee has requested authorization and coverage for ultrasound ablation. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees uterine fibroids. The physician reviewer found that symptomatic uterine fibroids are a fairly common medical condition, and standard and definitive therapy for a patient with these clinical demographics is hysterectomy. There is increasing data to support the use of MR-guided focused ultrasound for treatment of uterine fibroids (Ikink, et al). However, there is limited information of the long-term comparative effectiveness in relation to the numerous additional therapeutic options available. In addition to the patients largest fibroid, there are still at least two other sizable submucosal fibroids that would remain. In this clinical setting, ultrasound ablation is not likely to be more beneficial for treatment of the patients medical condition than other standard options. Based upon the information set forth above, the requested procedure is 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 12-year-old female enrollee has requested reimbursement and prospective authorization and coverage for residential mental health treatment services from 7/1/15 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the residential treatment services provided from 7/1/15 forward were not and are not medically necessary for treatment of the patients medical condition. The patient presents with a complex mental health history which is complicated by loss of parents at an early age, living in an orphanage and international adoption. The patient has been diagnosed with major depressive disorder, dysthymic disorder (pervasive depressive disorder) and disruptive mood dysregulation disorder, which are potentially treatable with psychopharmacology. In this case, the patient has had a trial of Zoloft and Trileptal and is currently taking Lamictal. Given that the patient presents with treatable mental health conditions, psychopharmacological intervention needs to be more intensive. In addition, the primary focus of RAD related disorder is corrective emotional experience and intensive and dynamic family therapy. By placing the patient out of state, this aspect of the intervention is significantly comprised. In this clinical setting based on all of the documentation presented for review, the patient can be safely and effectively managed at a lower level of care in a less restrictive setting. Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3  A 57-year-old male insured has requested reimbursement for a gene test (CPT 0047U) provided on 
3/10/22. The Health Insurer has denied this request indicating that the services at issue were considered 
investigational for the evaluation of the insureds prostate cancer. The physician reviewer found that 
Oncotype DX genomic prostate score testing has been used to predict higher-grade disease in patients 
undergoing active surveillance. Many studies suggest that Oncotype DX can predict higher-grade 
pathologic features in patients undergoing active surveillance and can help guide shared decision-
making for very low-risk or intermediate-risk prostate cancer. According to the current medical 
literature, the addition of Oncotype DX can provide important risk information about how an individual 
tumor will likely behave and help direct treatment. The recommendations for patients with localized, 
locally advanced, post-radical prostatectomy and recurrent prostate cancer are based on prognosis, 
which is estimated through risk stratification. Based on NCCN recommendation, patients with low-risk or 
favorable intermediate-risk disease should be considered for evaluation with one or more tumor-based 
molecular assays including Oncotype DX. This patients biopsy of the prostate demonstrated Gleason 
3+3=6 prostate cancer with a PSA of 7.74 ng/mL. This is clinically staged as cT1c with NCCN low risk. 
Based on current NCCN guidelines, Oncotype DX genomic prostate score testing is recommended to 
determine subsequent treatment options including surveillance in patients with clinical NCCN low-risk 
prostate adenocarcinoma. All told, the gene test (CPT 0047U) provided on 3/10/22 was likely to have 
been more beneficial for the evaluation of the patients medical condition than any available standard 
therapy.