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

Summary Reviewer 

The patient is a 63-year-old female with a history of breast cancer. The patient has requested reimbursement for acute hospital admission from 6/04/21 through 6/06/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that outpatient management with oral analgesic medication and incentive spirometry is reasonable for rib fractures involving less than three ribs. The patient is at increased risk for complications, such as flail chest, pneumonia, pulmonary contusions or respiratory failure, when there are three or more ribs fractured. There is an increased risk of complications in individuals who are older than 65 years.  The presence of six or more rib fractures increases the risk for serious complications.  Pain control, pulmonary hygiene and mobility are the goals of care for individuals with severe rib fractures. The submitted documentation fails to demonstrate the medical necessity of the services at issue. Inpatient care is necessary when the patientas signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient had three rib fractures but was admitted in stable condition with minimal pain. The objective data supported that she was stable. While close monitoring was appropriate, she could have been treated at a lower level of care. Therefore, acute hospital admission from 6/04/21 through 6/06/21 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


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 while a DAT-SPECT study is not indicated for all patients with a hand tremor, it has been shown to be useful in cases where the diagnosis of essential tremor and Parkinsons disease are both being considered and cannot be differentiated based on clinical grounds.  In this patients case, her provider suspected a possible essential tremor (or other tremor disorder).  It is imperative to provide a definitive diagnosis as treatment for essential tremor and Parkinsons disease are quite different, and the treatments for Parkinsons disease can have significant side effects.  In this particular case, the patients diagnosis was confirmed using this study and the patient was able to be appropriately counseled.  Therefore, DAT-SPECT scan performed on 9/17/15 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: Experimental
Decision: Overturned

Summary Reviewer 1

The patient is a 17-year-old female with migraine headaches, postural orthostatic tachycardia syndrome, and significantly elevated lactate. Her headaches have been treated with several medications, with some reduction in pain, but she continues to miss school for the associated symptoms of nausea and dizziness. Her provider suspected a mitochondrial disorder and ordered mitochondrial DNA sequencing. The Health Insurer has denied reimbursement for genetic testing (mitochondrial genome sequencing) performed on 12/31/16. Per the Health Insurer, the services at issue were investigational for the evaluation of this patient.  There is sufficient support for the services at issue in this clinical setting. Mitochondrial disorders are challenging to diagnose because they can present at any age, have a wide spectrum of clinical symptoms, and are often insidious in onset.  Because energy production is a need of all tissues, mitochondrial disease can present with virtually any symptom. While there are some well-described mitochondrial syndromes, many patients with mitochondrial disease do not fall neatly into one of the described syndromes.  The advent of mitochondrial genome sequencing and whole exome sequencing have obviated the need for invasive testing, such as muscle biopsy. Patients with mitochondrial disease need comprehensive multidisciplinary care, optimally through a mitochondrial specialty center. There are consensus-based guidelines for treatment and surveillance of these multisystem disorders. In order to determine whether these recommendations should be applied to the patient, a diagnostic evaluation is needed to determine whether a mitochondrial disorder is responsible for the patients symptoms. Mitochondrial genome sequencing is an integral part of such a diagnostic evaluation, and is standard of care for the evaluation of mitochondrial disorders. Therefore, genetic testing (mitochondrial genome sequencing) performed on 12/31/16 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: Experimental
Decision: Overturned

Summary Reviewer 3


A 60-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 7/8/16. 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 the digital breast tomosynthesis performed on 7/8/16 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Ciatto and colleagues investigated the effect of integrated two-dimensional (2D) and three-dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls. Based on the support in the medical literature, the use of breast tomosynthesis 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 2

A 66-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Expression Assay provided on 10/12/17. 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 that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma Gene 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 the evaluation of this patients melanoma. Moreover, the DecisionDx-Melanoma Gene Assay was not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma Gene Expression Assay provided on 10/12/17 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a 13-year-old male enrollee has requested authorization and coverage for Genotropin 12 mg cartridge. 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 the U.S. Food and Drug Administration (FDA) has approved the use of growth hormone therapy for idiopathic short stature or non-growth hormone-deficient short stature, defined as height standard deviation less than or equal to -2.25 or less than or equal to 1.2nd percentile for age and gender and who are considered unlikely to reach a normal adult height. In 2016, the Pediatric Endocrine Society came out with guidelines and recommendations for growth hormone use and indicated the decision to treat in idiopathic short stature should be made on case-by-case basis. The guidelines also suggested a follow-up assessment of benefit in height standard deviation and psychosocial impact 12 months after growth hormone initiation and dose optimization. This patient has a very low growth velocity of 2.75 cm per year. He has a poor height prediction of less than 160 cm, which is below the -2.25 standard deviation for the U.S. adult male population. Based on the records, this patient meets the criteria for idiopathic short stature and meets the FDA criteria for treatment with growth hormone therapy. Therefore, Genotropin 12 mg cartridge is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a 17-year-old female enrollee has requested reimbursement for intensive outpatient services provided from 3/01/18 through 6/30/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2 due to the patients history of recent ideation and hospitalization. With regards to functional status, the records support a score of 2. The patient had deterioration in expected level of functioning in relationships with peers, adults and family. In terms of comorbidity, the records support a score of 2. The patient did not have medical problems and had apparent active substance use. With regards to level of stress of the recovery environment, the records support a score of 3. The patient has problematic issues with family relationships. In terms of level of support of the recovery environment, the records support a score of 2. The patients family actively participated in treatment. However, their relationship was strained. With regards to resiliency and treatment history, the records support a score of 3 due to recent minimal progress in the intensive outpatient program. In terms of acceptance and engagement, the records support a score of 3. The patient participated, but appeared ambivalent. In terms of acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians. Thus, the patient has a composite score of 19. The score correlates with intensive outpatient services. Therefore, intensive outpatient services provided from 3/01/18 through 6/30/18 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The patient is a 61-year-old female with cutaneous melanoma on the left ear. A pathology report revealed non-ulcerating malignant melanoma extending to a depth of 2.65 mm, stage pT3A. The DecisionDx melanoma assay report dated 6/30/14 noted findings of a Class 2 molecular signature associated with a high risk metastatic disease within five years. The patient has requested reimbursement for the DecisionDx melanoma assay provided on 6/30/14. The Health Insurer has denied this request indicating that the testing at issue was considered investigational.  Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. While the majority of clinical stage I patients will be disease-free at five years, some stage I patients will develop advanced disease. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. DecisionDx melanoma assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class 1 consistent with a low risk of metastasis or Class 2 suggestive of a high risk of metastasis. One peer-reviewed publication indicated that there was a statistically significant association of a Class 1 signature by DecisionDx melanoma assay for primary dermal melanoma (PDM), whereas cutaneous metastatic melanoma (CMM) were more frequently Class 2 (Sidiropoulos, et al). The authors concluded that the melanoma prognostic assay may be a useful tool for distinguishing PDM from CMM. According to the results of analysis of this patients melanoma performed with DecisionDx melanoma assay, the tumor was classified as Class 2 with a high risk of near-term (within five years) metastatic disease. Therefore, DecisionDx melanoma signature may be an independent predictor of metastasis risk. Identification of the increased risk of recurrence of melanoma in this patient helped establishing appropriate follow-up plan to improve the outcome in this particular patient. All told, the DecisionDx melanoma assay performed on 6/30/14 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 1

A 55-year-old female enrollee has requested reimbursement for gene test (molecular profiling) performed on 2/18/16. 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 lung cancer.The physician reviewer found there is some support for a portion of the services at issue in this clinical setting. Specifically, testing for the T790M mutation was beneficial. Genomic testing, using the Guardant360 test, interrogates more than 72 genes while all that is required. However, the National Comprehensive Cancer Network (NCCN) guidelines note that for patients with known EGFR mutation, testing for the T790M EGFR mutation is recommended. As such, in this patients case, there was a clinical benefit from testing for the T790M mutation and for the portions of the panel. Prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. There is a lack of published trials that demonstrate the clinical utility of this genomic testing. The available literature on its 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 on clinical utility. In addition, there is potential for harm if ineffective therapy is provided based on test results because there may be adverse effects of therapy in absence of a benefit. As a result, the use of expanded mutation panel testing for targeted treatment in cancer is considered investigational and should only be conducted in the setting of a clinical trial. All told, a portion of the gene test (molecular profiling) performed on 2/18/16 was likely to have been more effective than the available standard therapy for the evaluation of this patients medical condition. Based upon the information set forth above, a portion of the services 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 partially overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

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 this patient has recurrent metastatic disease. He has been well managed so far and was empirically tried on standard regimens. Since his tumor has progressed, referral for clinical trials is appropriate. This could be facilitated by mutational testing of the tumor. Some testing that may provide insight are KRAS, TP53, and BRAF, which are included in these panels. BRAF mutations may suggest alternative targeted therapies that may be better than those selected empirically. Von Hoff and colleagues performed a study of 86 patients. The progression-free survival on regimen selected by molecular profiling was compared to the progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has significant results for patients with stage IV tumors. In this patients case, the results from molecular profiling may offer a rational selection of the next regimen. Thus, 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 28-year-old male enrollee has requested reimbursement for code L0456 provided on 1/13/16. The Health Insurer has denied this request and reported that the equipment at issue was not medically necessary for treatment of the enrollee, who had a history of neck pain, upper back pain, and shoulder pain. The physician reviewer found there are no indications in the records forwarded for review that the patient had a condition that required the use of a thoracolumbosacral orthosis.  There are no indications in the records, for instance, that the patient has an unstable bony spine (e.g., fracture or significant spondylolisthesis) or that he recently underwent destabilizing spinal surgery.  The records indicate that the patient had neck and upper back pain following a twisting and falling injury while putting away holiday decorations.  A lumbosacral orthosis was not appropriate for this patients condition.  There is a lack of objective evidence that it is an effective measure to treat any spinal condition in the absence of objective instability or postoperatively. There is a lack of high-grade published data that this type of intervention favorably impacts the natural history of sprain/strain/enthesopathic spinal conditions in a clinically meaningful manner.  Clinically, they are generally considered contraindicated because they can promote core weakness, which is the opposite of appropriate treatment.  All told, code L0456 provided on 1/13/16 was not medically necessary for the treatment of this patient. Therefore, the equipment at issue was 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 51-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 9/29/20. 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 understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing prognostic information, the value of next generation sequencing (NGS) to predict candidates for specific mutation-driven treatment holds promise. Patients with inflammatory and metastatic breast cancers benefit from NGS to identify markers that may indicate benefit from targeted treatment or clinical trials. The use of NGS, such as with Guardant360, is likely to be more effective than available standard therapy. Therefore, Guardant360 testing performed on 9/29/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 38-year-old male enrollee has requested authorization and coverage for sirolimus cream. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. Tuberous sclerosis is a rare genetic disease, and there are not enough patients to have double blind, placebo-controlled studies for the treatment of the associated facial angiofibromas. Topical rapamycin or sirolimus is considered standard of care for the treatment of these lesions.  The International Tuberous Sclerosis Complex Consensus Statement also recommends the use of this medication for treatment of facial angiofibromas in tuberous sclerosis. Therefore, sirolimus cream is likely to be more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 40-year-old male enrollee has requested reimbursement for therapeutic exercises and application modality infrared services (CPT 97026 and 97110) provided from 8/13/15 through 10/31/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees lower back pain. The physician reviewer found this patient that underwent therapeutic exercises and infrared therapy for the treatment of acute lower back pain. There is a lack of documentation demonstrating sustained, objective functional or ADL improvements obtained with therapeutic exercises and infrared therapy. In addition, there is a lack of support in the peer-reviewed literature for the services at issue in this clinical setting. Given the lack of support in the peer-reviewed literature and the documentation submitted for review, the therapeutic exercises and application modality infrared services (CPT 97026 and 97110) provided from 8/13/15 through 10/31/15 have not been established as medically necessary for treatment of the patients medical condition. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.