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

Summary Reviewer 1


A 60-year-old male enrollee has requested reimbursement for the subtalar arthrodesis provided on 11/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees hallux valgus. The physician reviewer found that this patient presents with an adult onset painful flatfoot and hallux valgus. The treatment under review had been successfully used on the other foot, which consisted of a calcaneal osteotomy, subtalar arthroereisis and tight wire management of hallux valgus. As isolated arthroereisis has limited benefit, when accompanied by other flatfoot correcting procedures, it has the ability to provide better results than attempting the subtalar blocking procedure alone. This patients care included a soft tissue hallux valgus tethering with rear foot re-orienting. In concert with the calcaneal osteotomy, a second procedure increases the potential for an improved result. The subtalar implant is not a procedure that should be performed alone and it does have complications but it appears to have the potential to provide a better outcome. Thus, the subtalar arthrodesis provided on 11/23/15 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were 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 59-year-old male enrollee has requested reimbursement for gene testing performed on 9/13/16. The Health Insurer has denied this request indicating that the requested services were not medically necessary for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of clinical trials. There is lack of evidence as to its efficacy and how the results would change treatment recommendations, such as in this case. Accordingly, the services at issue are not considered to be standard of care in this clinical setting. Therefore, gene testing performed on 9/13/16 was not medically necessary for the evaluation of this patients medical condition. Based on the information above, 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: Overturned

Summary Reviewer 2


A 63-year-old female enrollee has requested reimbursement for breast magnetic resonance imaging (MRI) performed on 3/14/16.   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 that breast MRI has an important role in both screening and diagnostic settings.  In the last several years, several organizations, including the American Cancer Society and the American College of Radiology, have attempted to establish guidelines for the appropriate use of breast MRI.  The medical literature does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound.  In this patients case, the records document a calculated lifetime risk for developing breast cancer of 26.4%.  The National Comprehensive Cancer Network recommends that annual breast MRI be considered and begun 10 years prior to the age at which the youngest relative developed breast cancer.  In her case, her daughter developed relatively severe breast cancer at age 42.  For this patient, MRI was warranted.  Therefore, MRI of the breasts performed on 3/14/16 was 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 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 59-year-old male enrollee has requested authorization and coverage for spinal cord stimulator. The Health Insurer has denied this request and reported that the requested device is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the medical evidence supports the requested device in this clinical setting. Wong and colleagues concluded that the option of spinal cord stimulation should be considered after conservative therapy has failed. They pointed to large randomized control studies which showed that high frequency forms of stimulation was effective for chronic low back pain. A systematic review and meta-analysis by Taylor and colleagues concluded that spinal cord stimulation is an effective pain relieving treatment for chronic low back and leg pain with or without a prior history of back surgery.  The mean level of pain relief across 74 studies was found to be 58% at an average follow-up of 24 months. All told, the requested spinal cord stimulator is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 22-year-old female enrollee has requested authorization and coverage for Orencia. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees rheumatoid arthritis. The physician reviewer found that the current guidelines recommend tumor necrosis factor (TNF) inhibitors as first-line therapy for patients with active rheumatoid arthritis. The U.S. Food and Drug Administration (FDA) has approved Orencia for the treatment of patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more disease modifying anti-rheumatic drugs (DMARDs) or TNF inhibitors (Maxwell and Singh). Orencia appears to be most effective in patients with active rheumatoid arthritis resistant to either methotrexate or the combination of methotrexate and anti-TNF agents and methotrexate naive patients with early rheumatoid arthritis and poor prognostic indicators (Kremer, et al). These indicators include patients who are methotrexate naive and seropositive for rheumatoid factor (RF), anti-cyclic citrullinated protein (CCP) type 2 or both and had radiographic evidence of joint erosions (Westhovens, et al). This is a case of a patient with presumed active seronegative rheumatoid arthritis who is intolerant to methotrexate. However, the medical records fail to demonstrate what dose and what reaction she had to the methotrexate. Moreover, the documentation does not include evidence of failure or intolerance or contraindications to TNF inhibitors. All told, Orencia is not supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested medication is 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 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma test performed on 10/19/18. 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, and 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 provided 10/19/18 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 23-year-old female enrollee has requested authorization and coverage for FirstStep Plus Cytogenomic Constitutional (Genome-Wide) Microarray Analysis. The Health Insurer has denied this request indicating that the requested services are investigational for the evaluation of the enrollees medical condition. The physician reviewer found Autism spectrum disorder is a biologically based neurodevelopmental disorder.  Identification of a genetic diagnosis may provide additional information about prognosis, expected outcome, and recurrence risk.  However, few studies have evaluated the effect of genetic testing on such outcomes, and it is unclear whether or not genetic testing affects health outcomes.  In this case, the documentation does not show how using genetic testing to diagnose autism spectrum disorder will directly impact treatment options.  In sum, the superior efficacy of FirstStep Plus Cytogenomic Constitutional (Genome-Wide) Microarray Analysis has not been established.  Based upon the information set forth above, the requested services are 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 17-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health residential treatment provided from 6/28/19 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Psychiatric Association treatment guidelines for eating disorders recommend either an inpatient unit or residential treatment facility when lower levels of care have been tried and failed. Additionally, the presence of comorbid conditions is an important factor to consider when deciding on the appropriate level of care. This patients comorbidities include major depressive disorder with suicidal ideation. Brewerton and Costin noted that for patients with anorexia nervosa there were statistically significant improvements in mean body mass indexThe great majority of patients completing treatment showed significant improvement at discharge from intensive residential treatment. This patient is experiencing a disturbance in mood, affect or cognition resulting in disordered eating behavior that could not be safely managed in a less restrictive setting. Therefore, residential treatment is in accordance with generally accepted standards of medical practice. Thus, mental health residential treatment from 6/28/19 forward was and is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 40-year-old male enrollee has requested reimbursement for acupuncture services (CPT code 97810) provided from 8/13/15 through 10/31/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees abdominal pain. The physician reviewer found the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Most studies regarding acupuncture for the treatment of abdominal pain are inconclusive. Lan and colleagues stated that It remains unknown whether manual acupuncture or electroacupuncture is more effective or safer than other treatments for patients with [functional dyspepsia] FD. Given the lack of support in the peer-reviewed literature, acupuncture services (CPT code 97810) provided from 8/13/15 through 10/31/15 were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 24-year-old male enrollee has requested reimbursement for mental health inpatient treatment from 8/03/16 through 8/04/16.  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 the submitted documentation supports the medical necessity of the services at issue.  Premature discharge of patients with severe mental illness and prominent psychosis not only increases patient morbidity and the chances of prompt re-admission, but also exposes the general population to preventable risk of harm.  This patient had an underlying formal thought disorder with violent outbursts at home and recent aggression with homicidal ideation.  On 8/03/16, the patient remained psychotic, anxious and guarded.  He was assessed to have poor insight, judgment and impulse control.  The provider further determined that the patient remained a potential threat to self and others due to his psychotic burden.  After liaising with family and the outpatient psychiatrist, a medication change was made on 8/03/16, and a rather recently released antipsychotic medication, cariprazine, replaced one of the other antipsychotic agents.  In sum, on 8/03/16, the patient was still suffering from the illness burden that prompted the admission.  He was engaged in active treatment during the entire hospital stay, which included evidence-based psychiatric care and communication with family and outpatient providers to promote a seamless transition back to the community.   During the disputed timeframe, the acute inpatient setting was reasonably expected to both improve the patients condition and prevent a more serious episode of illness.  Thus, mental health inpatient treatment from 8/03/16 through 8/04/16 were medically indicated 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: Overturned

Summary Reviewer 

A 50-year-old male enrollee has requested reimbursement for mandibular advancement device (E0486) provided on 12/14/18. The Health Insurer has denied this request and reported that the device at issue was not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the Health Insurer denied reimbursement for the device at issue claiming that the patient did not fail continuous positive airway pressure (CPAP) treatment as a first-line of treatment prior to use of the mandibular advancement device. The Health Insurer also noted that the patient did not qualify to be diagnosed with obstructive sleep apnea as his apnea-hypopnea index was 4 per hour, and his RDI was 12 per hour. The term RDI has been defined differently when used with portable monitors (home sleep study). Portable monitors are likely to underestimate the severity of events compared to the apnea-hypopnea index by polysomnography. The American Academy of Sleep Medicine recommends that providers consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. This recommendation supports the use of mandibular advancement device if the patient prefers it as a first-line of treatment even without showing intolerance to CPAP. Therefore, the mandibular advancement device provided on 12/14/18 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 45-year-old female enrollee has requested reimbursement for FoundationOne gene testing performed on 3/26/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees adenosarcoma of the cervix.        The physician reviewer found the molecular profiling of an individuals cancer cells is an assay of genomic of molecular abnormalities. The goal would be to identify a target at which a specific treatment could then be offered. Though of real scientific interest, as yet there is a lack of  convincing evidence that the assay adds to the decision making ability to improve patient outcomes. Von Hoff and colleagues, in a pilot study, explored the value of molecular profiling but the results are not convincing. The seriousness of utilizing molecular profiling is expressed in various medical literature but ongoing research must still be explored. In an editorial, Doroshow noted the serious limitations of various non-randomized studies exploring the value of molecular profiling. This viewpoint was also expressed in an editorial by West in 2016.  Moreover, a recent randomized trial did not demonstrate significant clinical benefit from choosing therapy based on molecular targets (LeTourneau, et al).  Therefore, the services at issue were not likely to be superior to any available standard therapy for treatment of this patients cancer. 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: Experimental
Decision: Upheld

Summary Reviewer 2


A 37-year-old male enrollee has requested authorization and coverage for placing devices in neck (insertion of more than one artificial intervertebral disc).  The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition.  The physician reviewer found that the requested neck surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Two level total disc arthroplasty has become accepted by the community of spinal surgeons, both neurosurgeons, and orthopedists, to be superior in most instances, to a two level fusion. There is a growing body of evidence in the peer-reviewed literature that demonstrates two level total disc replacement is associated with a lesser incidence of adjacent level disease than a two level anterior cervical fusion. Based upon the information set forth above, the requested services are 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 1

A 64-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that upon review of available data, proton therapy may be equivalent to, but not more beneficial than standard available therapy with photon based intensity modulated radiation therapy (IMRT) for prostate cancer. Proton therapy provides a Bragg peak, resulting in decreased dose before and after the peak, which translates into a decrease in exposure of normal tissue in the low- to intermediate-dose range, but not in the high-dose range (Trofimov, et al). Dosimetric studies have shown a benefit in bladder and rectal exposure with this regard. However, these findings do not appear to result in decreased clinical side effect (Sheets, et al; Coen, et al; Yu, et al; Hoppe, et al). Cancer control rates are also reportedly similar between photons and protons (Coen, et al). Accordingly, the requested proton beam radiation therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. 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 

The patient is a 20-year-old female who has a history of alopecia totalis. The patient has requested authorization and coverage for Xeljanz (tofacitinib citrate tablet 5 mg). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. Standard of care for the treatment of alopecia totalis/universalis includes systemic steroids, methotrexate, cyclosporine, Janus kinase inhibition, and contact sensitization with diphenylcylopropenone or squaric acid. Few treatment methods have been evaluated by randomized controlled trials to determine the most efficacious modalities to treat alopecia areata. Therefore, it is challenging for clinicians to guide patients regarding the best therapeutic options. Janus kinase inhibitors, like Xeljanz, do show excellent promise and some great results in treating extensive alopecia. This patient has already had a trial of Xeljanz, is tolerating it well, and is achieving a reduction in her SALT score. Janus kinase inhibition has been found to be well tolerated and effective in the treatment of alopecia. Therefore, Xeljanz (tofacitinib citrate tablet 5 mg) is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 54-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 6/01/15.  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 there is sufficient support for the services at issue in this clinical setting.  As noted by Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Per Ciatto and colleagues, integrated two-dimensional and three-dimensional mammography improves breast-cancer detection and has the potential to reduce false positive recalls.  All told, digital breast tomosynthesis performed on 6/01/15 was likely to have been superior over other methods of evaluation.  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.