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

Summary Reviewer 3

The patient is a 59-year-old female with a malignant melanoma of the left lateral chest. Pathology showed Breslow thickness of 1.28 mm, Clark level IV. The margins of excision were free of melanoma. Molecular profiling with DecisionDx-Melanoma testing was performed on 5/12/16. The patient has requested reimbursement for gene testing performed on 5/12/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  This patient had an early stage melanoma. The National Comprehensive Cancer Network guideline states 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. The results of this testing are not likely to alter treatment and surveillance recommendations. Thus, gene testing performed on 5/12/16 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: Overturned

Summary Reviewer 1


A 68-year-old male enrollee has requested reimbursement for the positron emission tomography (PET) scan performed on 2/3/15. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for evaluation of the enrollees cognitive impairments, neuropsychiatric symptoms and parkinsonian features.  The physician reviewer found that the PET scan performed on 2/3/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. PET is a standard procedure performed by providers when dementia is atypical, and most specifically to differentiate Alzheimers disease from frontotemporal dementia. This diagnostic procedure allows the patient and his family to better understand prognosis and treatment, and guide the treating provider to provide the best treatment. In this case, MRI showed nonspecific atrophy. The EEG showed spike and slow wave discharges suggesting epilepsy. In addition, neuropsychology testing suggested frontotemporal dementia, and the examination showed Parkinsonian features. The patient presented with a subacute onset of progressive memory problems. In this complex clinical setting, the diagnostic procedure at issue 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 diagnostic procedure 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: Upheld

Summary Reviewer 3

A 57-year-old female enrollee has requested reimbursement for the DecisionDx-Melanoma Assay provided on 7/20/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma. The physician reviewer found the medical evidence does not support the superior efficacy of the services at issue in this patients case. The records document melanoma of 1.02 mm Breslow depth on the left labia. The National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma Assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in this clinical setting. DecisionDx-Melanoma Assay is not expected to impact the treatment or outcome of the patients melanoma. Thus, DecisionDx-Melanoma Assay performed on 7/20/18 was not likely to have been more efficacious than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3 
A 28-year-old female insured has requested authorization and coverage for intravenous (IV) 
Gammagard. The Health Insurer has denied this request indicating that the requested treatment is 
considered investigational for the treatment of the insured's refractory relapsing polychondritis. 
The physician reviewer found that there is limited medical literature studying IVIG as a treatment 
option for patients with relapsing polychondritis. Relapsing polychondritis is a rare autoimmune 
disorder, and official guidelines to utilize certain therapies are not likely to be available in the near 
future. However, for patients who have tried and failed treatment with multiple therapies from 
several classes of medications, IVIG is appropriate as the next-line treatment option. This is 
particularly applicable when its efficacy has been established for a particular patient in keeping 
the disease stable or in remission. According to one study by Lekpa and Chevalier, IVIG has been 
shown to be effective in some patients with relapsing polychondritis. In this case, the patient 
presents with relapsing polychondritis. The records provided for review indicate that the patient 
has tried and failed treatment with multiple therapies from several classes of medications. The 
provider has recommended a continuation of IVIG therapy which has already been shown to be 
the most effective treatment option for this patient. All told, the requested IV Gammagard is likely 
to be more beneficial for the treatment of the patients condition than any available standard 
therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 51-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 4/15/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the Anser IFX Test is a quantitative measurement of serum infliximab and anti-infliximab antibodies.  Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment.  The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  However, there is a lack of well-controlled clinical trials to confirm that use of the Anser IFX test leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  In addition, there are technical factors relating to the use of different assay methods across studies.  It has not yet been established whether the use of threshold levels aids in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  In sum, Anser IFX testing performed on 4/15/14 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 3

A 55-year-old female enrollee has requested authorization and coverage for arthrodesis of sacroiliac (SI) joint (27279). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees SI joint pain. The physician reviewer found the request for arthrodesis of SI joint (27279) is not likely to be beneficial for this patient. The reliance of steroid local injection into the SI joint as an indicator for identification of a specific pain generator is not sufficient to localize pain generation from the SI joint in the face of multifactorial chronic pain. Local anesthetic injection is questionable since the SI joint is large and irregular and only acceptable to needle intervention in portions of the joint. In sum, it is not likely to be beneficial for this patient to undergo SI instrumentation and fusion as a treatment method for her condition of chronic pain. Based upon the information set forth above, the requested services are 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: Overturned

Summary Reviewer 


A 50-year-old female enrollee has requested authorization and coverage for the prescription drug Aubagio.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees multiple sclerosis. The physician reviewer found that Aubagio is one of three oral therapies now available to treat relapsing forms of multiple sclerosis.  Aubagio is a standard therapy for multiple sclerosis.  There is a lack of data indicating that the required next step of using Rebif is medically a more sound decision. There is a lack of head-to-head data showing Rebif to be more efficacious or safe than Aubagio.  Clinical experience shows that Aubagio as an oral agent does not cause injection site reactions or flu-like symptoms.  All told, Aubagio is medically indicated for the treatment of this patient.  Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 61-year-old male enrollee has requested authorization and coverage for Tykerb. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient has a salivary gland cancer, which is a rare tumor that has a high propensity for distant metastases.  Stage IV disease, as in this case, is very difficult to treat because it is poorly responsive to conventional chemotherapy regimens. Since the tumor is rare, large randomized clinical trial evidence cannot be expected. Patients with refractory or relapsed cancer who have exhausted standard treatments are usually considered for clinical trials. Recently, it has become important to identify mutations that may be amenable to targeted therapy. 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 patient was treated with paclitaxel and trastuzumab along with directed stereotactic radiotherapy of the brain metastases. The records documented disease progression, and his provider is attempting to target the HER2 amplification by lapatinib. There is phase II data demonstrating that this drug may induce stable disease in patients with salivary gland cancers. It also penetrates the blood-brain barrier and may be more effective than trastuzumab. Thus, Tykerb is likely to be more effective than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary  
The patient is a 36-year-old female with a history of class 3 obesity complicated by prediabetes and 
dyslipidemia. The records available for review indicate that the patient had a body mass index (BMI) 
over 40 kg/m2 in September 2021. The physician reviewer found that at issue is whether the requested 
Wegovy is medically necessary for the treatment of this patient. According to Gadde and colleagues, 
while lifestyle modification is recommended as the cornerstone of obesity management, many patients 
do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and 
neurohormonal adaptation of the body in response to weight loss. There are multiple pharmacologic 
therapies available for weight management. Wegovy is a member of a class of medications known as 
glucagon-like peptide 1 (GLP-1) analogs. As noted in the medical literature, GLP-1 analogs have been 
shown to improve glycemic control, reduce body weight, and decrease cardiovascular risk (Knudsen and 
Lau). Studies have demonstrated Wegovys ability to promote weight loss via reduced appetite and 
energy intake and delayed gastric emptying (Cornell). In this case, the patient has a history of class 3 
obesity complicated by prediabetes and dyslipidemia. The records reflect that the patient has attempted 
treatment with diet management and exercise without significant benefit. The patient has also tried and 
failed treatment with medications such as phentermine. Overall, Wegovy has been shown to effectively 
promote weight loss for patients in conjunction with diet and exercise. Therefore, the requested 
Wegovy is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 20-year-old female enrollee has requested reimbursement for residential treatment center (RTC) services provided from 5/15/16 through 5/17/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees eating disorder.   The physician reviewer found the records provided for review indicate this patient was not in need of 24-hour per day monitoring and supervision. In addition, she was not likely to require inpatient hospital admission if discharged from RTC level of care. The patient was above her ideal body weight, was not suicidal or psychotic, and had normal laboratory data. The patients depression could have been safely and adequately managed at a lower level of care. The patients needs could have been safely and adequately managed in a less restrictive treatment setting as well. All told, the RTC services provided from 5/15/16 through 5/17/16 were not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 57-year-old female enrollee has requested authorization and coverage for endovenous ablation therapy of incompetent vein. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees chronic venous insufficiency. The physician reviewer found that the documentation does not support the medical necessity of the requested endovenous ablation therapy of incompetent veins for treatment of this patients varicosities. The most recent evaluation documents that the patient is doing well and is without complaints or concerns and is using compression stockings as prescribed. Therefore, there is no indication for additional treatments. Accordingly, the requested endovenous ablation therapy of incompetent vein is not supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 65-year-old female enrollee has requested reimbursement for collagen crosslink testing and homocysteine testing provided on 12/03/18. 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 osteoporosis is a condition of thinning of the bones that leads to increased risk of fracture. It is defined by the World Health Organization as a bone mineral density of 2.5 standard deviations or more below the mean peak bone mass as measured by dual-energy x-ray absorptiometry (DEXA).  Bone mineral density (BMD) assessment, via DEXA, is still the criterion standard for evaluation and diagnosis of osteoporosis. However, because changes in bone mass and density in response to antiresorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover may be a useful adjunct in monitoring of osteoporotic patients treated with antiresorptive agents. Evidence suggests that biochemical markers could be useful in making therapeutic decisions because, in general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine. The medical evidence supports collagen crosslink testing in this clinical setting. However, there is a lack of support for homocysteine testing in this patients case. Ohishi and colleagues found that serum total homocysteine levels had no correlation with bone mineral density. While some studies have suggested that there may be an association between homocysteine levels and bone loss, to date, the association between homocysteine imbalance and its role in bone loss remains unclear. Enneman and colleagues noted plasma levels of homocysteine were significantly inversely associated with both bone ultrasound parameters and with bone mineral density. However, the size of the associations seems to be of limited clinical relevance and may, therefore, not explain the previously observed association between plasma homocysteine and osteoporotic fracture incidence. In sum, collagen crosslink testing provided on 12/03/18 was likely to have been more beneficial than other available methods of evaluating this patient. However, the superior effectiveness of homocysteine testing has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


An 18-year-old female enrollee has requested reimbursement for mental health residential treatment provided from 6/23/17 through 7/16/17. 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 submitted documentation supports the medical necessity of the services at issue. The patient has an extensive psychiatric history involving multiple prior inpatient treatment programs. The patient had a serious suicide attempt on 5/26/17 with Ativan and Vodka, which can be a lethal combination. The patient has a history of self-harm and is impulsive. She was ambivalent about treatment goals. It appears that the patient decompensated in less restrictive settings. There is sufficient support for the services at issue in this clinical setting. The records indicate that the patient had failed less restrictive means for treatment. Thus, mental health residential treatment provided from 6/23/17 through 7/16/17 was medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 61-year-old male enrollee has requested reimbursement for proton beam radiation therapy provided from 6/26/19 through 8/29/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that currently, there is a lack of clinical data in the medical literature to suggest that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for tumors of the head and neck area. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy (IMRT). A comparative analysis by Sio and colleagues found no significant difference in symptom burden in the acute and chronic phases of treatment with proton therapy compared to photon therapy for head and neck cancer. The American Society of Radiation Oncology (ASTRO) emerging technology committee report on proton therapy specifically states that there is insufficient data to recommend proton beam therapy for routine head and neck radiation therapy outside of clinical trials. The comparative plan was reviewed in detail and shows that standard treatment methods are sufficient to treat this patient and that the proton therapy plan does not result in a meaningful clinical difference despite having lower dose to one of the parotid glands. Consensus group guidelines do not support the use of proton therapy in this setting. There is a lack of level I evidence to support the use of proton therapy for the treatment of head and neck cancer. Therefore, proton beam radiation therapy provided from 6/26/19 through 8/29/19 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 40-year-old female enrollee has requested reimbursement for testing for inherited thrombophilic disorders performed on 10/19/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that testing for thrombophilias after early miscarriage has not been shown to be clinically useful in the low risk population. Finding a genetic mutation in this population for MTHFR, Factor V (Leiden) or prothrombin genes would not change the clinical management of the patient currently or with a new pregnancy. Testing for these mutations has only been found to be clinically useful in a patient who has a personal history of a venous thrombotic event or a first-degree relative with gene mutation who has had a venous thrombotic event. In this case, the literature does not support testing for these mutations because there would be no change in clinical management. All told, testing for inherited thrombophilic disorders performed on 10/19/19 was not likely to have been more beneficial than other available methods of evaluating this patient.