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

Summary Reviewer 


The parent of a 15-year-old female enrollee has requested reimbursement for psychiatric residential treatment center (RTC) services from 5/13/15 through 12/31/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found upon review of the documentation provided, records from 5/13/15 through 12/31/15 show no evidence that the patients behaviors were out of control, or that the patient was psychotic or a danger to herself or others.  Moreover, the records do not indicate that the patient required any special medical or nursing treatment that could not have been provided in a setting other than 24-hour level of care. The notes indicate normal therapy sessions that could have taken place if the patient were an outpatient rather than in a residential setting. The patient was generally cooperative and participated in therapy. She was not aggressive, combative, or incoherent. There is no documentation of particular treatment techniques that would have required an inpatient treatment setting. The patients psychiatrists notes consistently show that the patient was making good progress and that both Seroquel and lithium were no longer needed and were discontinued. Based upon the information stated above, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2
The parent of a 17-year-old female enrollee has requested reimbursement for autonomic testing performed on 8/24/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees chronic fatigue and presumed postural orthostatic tachycardia syndrome (POTS).   The physician reviewer found this patients provider was faced with a diagnostic conundrum of how much the patients chronic fatigue syndrome versus depression versus POTS were contributing to her overall loss of well-being. As part of the diagnostic work-up the patient received a comprehensive assessment of her autonomic nervous system with an evaluation that was positive for abnormal sudomotor function, borderline cardiovagal impairment and preserved cardiovascular adrenergic function. Given this patients presentation, evaluation with autonomic testing was appropriate because POTS may occur with co-morbidities including diabetes, chronic fatigue, sleep disturbances, dizziness, syncope, migraines, gastrointestinal disorders of a functional nature, fibromyalgia and joint hypermobility, but co-morbid conditions can occur with or without tilt-table-defined POTS. In addition, POTS subtypes can be defined by using small fiber and autonomic structural and functional criteria. Given the complexities in this patients case from a diagnostic perspective, the autonomic testing provided on 8/24/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 65-year-old male with a medical history significant for episodes of diffuse paralysis during which he appears to be conscious and conversant but unable to move freely due to profound weakness. The patient has requested reimbursement for genetic testing performed on 3/25/20. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that periodic paralysis is a group of inherited diseases that present as episodic muscle weakness and paralysis. Hyperkalemic Periodic Paralysis (HYPP, HyperKPP) is a rare condition that begins in childhood and can continue until middle adulthood or may even last into late adulthood. It presents as muscle weakness, ranging from mild weakness to paralysis. During these episodes, it is common to have higher than normal blood levels of potassium. The condition is caused by a mutation in the SCN4A gene that codes for voltage-gated sodium channel Na1.4. Several diagnostic modalities exist in assisting diagnosis, which includes genetic testing. Given the extreme phenotype of the patient in this case, coupled with the known molecular basis for periodic paralysis, genetic testing was medically necessary in order to provide adequate surveillance, enroll in studies and quantify recurrence risk. Therefore, genetic testing performed on 3/25/20 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 53-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene expression testing performed on 11/01/18. 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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index is believed to add a bit to these prognostics. DecisionDx-Melanoma gene expression testing is a study of 31 genes in an individualas melanoma cells. It then classifies that particular melanoma based on the risk of recurrence at five years. Gerami and colleagues reported on 217 cases, with good correlation between DecisionDx-Melanoma classification and prognosis in patients undergoing sentinel node biopsy. At this time, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. It is also not clear if the DecisionDx-Melanoma assay can be used to make clinical decisions. All told, DecisionDx-Melanoma gene expression testing performed on 11/01/18 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The parent of a five-year-old male enrollee has requested reimbursement for gene testing performed on 11/20/15. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees generalized epilepsy of unknown etiology. The physician reviewer found that ezugha and colleagues studied 82 children with developmental delay or seizures. The study found abnormalities on CMA in 20 children (23.5%), but found the highest yield on CMA in those with four or more additional clinical variables, including seizures, hypotonia, learning delay, hypotonia, dysmorphic features, developmental delay, or autism. In children with three or fewer of these variables, like this patient who has no additional variables besides epilepsy, the yield of CMA was 8.7%. Given that this patient does not have heath concerns outside of seizures, the likelihood of abnormal finding on CMA is likely to be low. In addition, CMA is recommended as standard of care in children with intellectual or developmental disability or multiple congenital anomalies. This patient does not meet these criteria. As such, the gene testing performed on 11/20/15 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 patient is an eight-year-old male with a past psychiatric history of attention 
deficit/hyperactivity disorder (ADHD), combined presentation, oppositional defiant disorder, 
and rule out autism spectrum disorder. The patients parent has requested authorization and 
coverage for dextroamphetamine-amphetamine ER 10 mg capsules SR 24H (#60 per 30 days). 
The physician reviewer found it is a fairly common occurrence in clinical practice to prescribe a 
long-acting stimulant (with a marketed duration of action of 12 hours) and have patients return 
to the clinic saying that the medication only lasts for a much shorter period of time. Despite 
the wide availability of long-acting stimulants which would eliminate the need for dosing 
multiple times a day, many patients (or their parents) report relief of symptoms with taking 
long-acting stimulant medications more than once per day or repeated use of short-acting 
stimulants following a long-acting stimulant dose. According to the FDAs Medication Guide for 
Adderall XR, On a mg/kg weight basis, children eliminated amphetamine faster than adults. 
The elimination half-life (t1/2) is approximately 1 hour shorter for d-amphetamine and 2 hours 
shorter for l-amphetamine in children than in adults. However, children had higher systemic 
exposure to amphetamine (Cmax and AUC) than adults for a given dose of Adderall XR, which 
was attributed to the higher dose administered to children on a mg/kg body weight basis 
compared to adults. Upon dose normalization on a mg/kg basis, children showed 30% less 
systemic exposure compared to adults. Individuals vary in the way they metabolize 
medication, and this has led to the development of pharmacogenetic testing. Some individuals 
may metabolize certain medications more rapidly than others and conversely there are others 
who are considered slow metabolizers when compared to the majority of individuals who 
metabolize medications at a typical rate. Those who metabolize medication more rapidly than 
normal may require higher than usual medication doses or greater frequency of dosing as 
seems to be the case with this patient. Given that the patient has had documented benefit from 
twice daily dextroamphetamine-amphetamine ER (Adderall XR) dosing with no significant side 
effects, dextroamphetamine-amphetamine ER 10 mg capsules SR 24H (#60 per 30 days) are 
medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 48-year-old female enrollee has requested reimbursement for genetic testing performed by Myriad Laboratories on 10/4/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for breast or ovarian cancer syndrome. The physician reviewer found that there is currently a lack of prospective randomized controlled studies showing improved outcomes with use of genetic testing in this setting. There is a paucity of data from clinical trials correlating the results obtained from similar tests with improved overall survival, progression free survival, or quality of life. Further, the National Comprehensive Cancer Network (NCCN) and American Society of Clinical Oncology (ASCO) guidelines encourage research to delineate the optimal use of panel-based testing, development of evidence-based practice guidelines as data emerges, and education of providers regarding challenges in the use of these tests (Daly, et al; Robson, et al). In the absence of data demonstrating improved health outcomes with use of these tests, the genetic testing performed by Myriad Laboratories performed on 10/4/17 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: Overturned

Summary Reviewer 2 
 
A 58-year-old male enrollee has requested reimbursement for therapeutic phlebotomy from 
1/6/21 through 1/26/21. The Health Insurer has denied this request and reported that the service 
at issue was investigational for the treatment of the enrollees hereditary hemochromatosis. The 
physician reviewer found that therapeutic phlebotomy is the preferred approach to removing 
iron in patients with hereditary hemochromatosis because it is highly effective and relatively 
devoid of toxicities. In this case, phlebotomy was indicated as the records noted a biopsy proven 
iron overload. While there is a range of ferritin and iron saturation goals, the recommended 
ferritin goal is 30 to 150 ng/mL and the recommended iron saturation goal is greater than 20%. 
In this case, laboratory results dated 12/14/20 showed a ferritin of 369 ng/mL and an iron 
saturation over 85%. Therefore, therapeutic phlebotomy from 1/6/21 through 1/26/21 was likely 
to have been more beneficial for treatment of the enrollee's condition than any available 
standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 64-year-old male enrollee has requested authorization and coverage for cetuximab (Erbitux) to be given in conjunction with FOLFIRI. The Health Insurer has denied this request and reported that the requested medication regimen is investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is no globally accepted first-line chemotherapy regimen for advanced, HER2-negative esophagogastric cancer, and practice is variable. Cetuximab in EGFR amplified tumors has been shown to be effective in patients with esophageal and gastric cancers and has been demonstrated to be well-tolerated in combination with fluorouracil based chemotherapy rather than other regimens. This patient is receiving first-line therapy for metastatic disease given prior treatment in 2006. There is sufficient support for the requested medication regimen in this setting. Thus, cetuximab (Erbitux) to be given in conjunction with FOLFIRI is likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The patient is a 64-year-old male with a history of high-risk prostate cancer. The patient was 
evaluated by a radiation oncologist who recommended a course of proton beam therapy. The 
Health Insurer has denied the requested services as not medically necessary for treatment of the 
patients medical condition. The physician reviewer found that overall, the utilization of proton 
beam therapy is not recommended for routine use in the treatment of patients with prostate 
cancer. Proton beam therapy has unique properties compared to standard photon beam therapy 
in its ability to deposit radiation dose and can potentially result in fewer areas of low scattered 
radiation dose. Proton beam therapy is currently utilized and most strongly indicated in settings 
where severe toxicities would result if normal tissue constraints cannot be met by photon beam. 
However, in the treatment of patients with prostate cancer, studies have failed to show that the 
use of proton beam therapy results in a demonstrable, clinically significant difference in overall 
survival, quality of life, or reduction of high-grade toxicities over photon beam therapy (Royce 
and Efstathiou). Proton beam therapy may be efficacious in the treatment of patients with 
prostate cancer in cases of unusual anatomy or in cases of re-irradiation of adjacent tissues. 
Volumetric modulated arc therapy (VMAT) is a standard photon therapy radiation technique that 
is frequently utilized to achieve clinically equivalent normal organ dose constraints as proton 
beam therapy (Schroeck, et al.; Nogueira, et al.). Excellent dose toxicity outcomes have been 
demonstrated for standard VMAT in locally advanced prostate cancer. In this case, the records 
provided for review indicate that this patient has high-risk prostate cancer, but there is a lack of 
documentation indicating that the patient had unusual anatomy or re-irradiation of adjacent 
tissues. Therefore, the requested proton beam therapy is not medically necessary for treatment 
of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 58-year-old female enrollee has requested authorization and coverage for Ibrance 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees breast cancer.  The physician reviewer found that Turner and colleagues reported that treatment with Ibrance and Faslodex is approved for ER positive metastatic disease. The authors reported that among patients with hormone receptor positive metastatic breast cancer who had progression of disease during prior endocrine therapy, Ibrance combined with Faslodex resulted in longer progression-free survival than Faslodex alone. Given this support, the requested Ibrance 100 mg is supported as 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 medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 54-year-old male enrollee has requested authorization and coverage for anterior dual fusion. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support in the medical literature for spinal fusion for the management of chronic regional low back pain. A multicenter randomized study by Brox and colleagues compared the effectiveness of lumbar instrumented fusion with cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. The authors found there was no advantage over instrumentation and fusion versus the conservative treatment method. The patient has well-documented multi-level cervical and lumbar degenerative disc disease. He has upper extremity neurological symptoms considered to reference cervical spine myelopathies. However his studies do not demonstrate instability on flexion extension views. MRI revealed a stable grade 1 spondylolisthesis at L3-4. This would not be addressed with an L4-S1 fusion which would likely aggravate that condition by increasing stresses at that level after fusion. In addition, the diagnosis of neural foraminal stenosis at the lumbar spine is weakly supported with anatomical studies and even if present can be addressed with the posterior approach laminotomy foraminotomy without fusion. In addition, upper extremities symptoms suggest an undiagnosed neurological disorder as a comorbidity. Therefore, the anterior dual fusion is not medically necessary for treatment of the patients medical condition. For the reasons provided, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 16-year-old male with short stature whose height ((shoe)?) measurement fell to less than the 3rd percentile at age 12 years. His weight tracked above the 5th percentile. He was evaluated in June 2015 and his peak growth hormone response to arginine and clonidine was 13 ng/mL. Insulin-like growth factor-1 (IGF-1) level was 232 ng/mL and insulin-like growth factor-binding protein 3 (IGFBP-3) was 2.6 mg/L. His thyroid function tests, serum chemistry panel, and hemoglobin were normal.  His bone age in January 2016 was 13 year 6 months at 14 years 8 months. In June 2016, he stood at 151.4 cm (height standard deviation score of -2.3), and his growth velocity was 5.0 cm per year. He was started on Nutropin in October 2016 for treatment of idiopathic short stature. In January 2017, his height was 156.7 cm (height standard deviation score of -2.01) and his weight was 50.3 kg (weight standard deviation score of -1.06). His height velocity was 9.1 cm per year. Pubic hair was between Tanner stages 3 to 4, and testicular volume was 15 cc. The patients parent has requested authorization and coverage for Nutropin AQ NuSpin 20 mg/2 mL pen injector to optimize height potential for the patient. The Health Plan has denied this request and reported that the requested medication is not medically necessary for treatment of this patient.  This denial is the subject of this appeal and determination. The patient is being treated for idiopathic short stature, and as of January 2017 appear to be in the midst of his pubertal growth spurt. Prior to initiation of growth hormone (GH), the patients height was 2.3 standard deviation score below the mean for his age and gender. His growth velocity was slow for age, and his bone age was mildly delayed. According to  the Pediatric Endocrinology Society guidelines, a trial of growth hormone therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations (SD) below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity less than the 25th percentile for bone age; (3) bone age more than 2 SD below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient meets the above criteria. Accordingly, Nutropin AQ NuSpin 20 mg/2 mL pen injector is medically necessary for treatment of this patient. Therefore, for the reasons state above, 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 2

A 25-year-old female enrollee has requested reimbursement for calprotectin fecal laboratory testing (CPT 83993) performed on 12/24/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. The physician reviewer found that the fecal calprotectin is useful to assess disease activity in Crohns disease. Kawashima and colleagues conducted a study to clarify the predictability of fecal calprotectin level for predicting endoscopic remission. The authors noted that fecal calprotectin was more accurate for predicting endoscopic remission in Crohns disease than C-reactive protein, albumin, white blood cell count, and platelet count. DHaens and colleagues noted that fecal calprotectin levels correlate significantly with endoscopic disease activity in inflammatory bowel disease. There is sufficient support for the services at issue in this clinical setting. Therefore, calprotectin fecal laboratory testing (CPT 83993) performed on 12/24/20 was likely to have been more beneficial than other available standard therapy.