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

Summary Reviewer 2


The parent of a two-year-old male enrollee has requested reimbursement for FirstStepDX Plus chromosomal microarray analysis.  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 the patient is a two-year-old male who was born at 38 weeks gestation following a pregnancy significant for hyperemesis requiring frequent antiemetic therapy and preterm labor at 32 weeks gestation requiring modified bed rest. He suffered an event prior to discharge characterized by choking followed by desaturation to the 20s with subsequent resuscitation efforts.  Persistent transaminitis lead to liver biopsy at eight weeks of age and a diagnosis of giant cell hepatitis.  He had difficulties with feeding, colic, and delayed achievement of usual gross motor milestones.  He currently receives physical therapy with ongoing gross motor delays.  Neurologic examination in March 2015 revealed increased deep tendon reflexes in his lower extremities, intermittent exophoria bilaterally, moderately decreased tone globally, inability to stand unassisted, and microcephaly. At that time, chromosomal microarray testing and fragile X testing were performed.  The Health Insurer has denied reimbursement for FirstStepDX Plus chromosomal microarray analysis.  Per the Health Insurer, FirstStepDX Plus chromosomal microarray analysis was investigational for the evaluation of this patient. The current medical evidence supports the services at issue in this patients case.  Use of chromosomal microarray testing now plays a central role in the evaluation and diagnosis of children with global developmental delay, cognitive delay, and autism spectrum disorders (ASD).  Use of buccal sampling is an acceptable means of obtaining material for study.  According to the literature, when coupled with a chromosomal microarray that contains single nucleotide polymorphic probes, analysis of buccal cells can maximize a clinicians opportunity to detect cytogenetic mosaicism. Based on the literature and current standard of practice, the services at issue were likely to have been superior over 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 32-year-old transgender female enrollee has requested authorization and coverage for CPT codes 21137, 21209, 15824 and 15876. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. The patient has been on hormone therapy. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life. World Professional Association for Transgender Health (WPATH) states, Non-genital surgical procedures notably facial feminization surgeryare often of greater practical significance in the patients daily life than reconstruction of the genitalsThese reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. Therefore, CPT codes 21137, 21209, 15824 and 15876 are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 63-year-old female enrollee has requested reimbursement for breast tomosynthesis (three-dimensional mammogram) performed on 10/31/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found the medical literature supports the service at issue in this patients case. Skaane and colleagues noted 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.  Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  In sum, three-dimensional mammogram performed on 10/31/16 was likely to have been more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 50-year-old female enrollee has requested reimbursement for CPT code 81479 (unlisted molecular pathology, Cxbladder) performed on 12/19/18. 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 the medical evidence does not support the services at issue in this clinical setting. Cxbladder testing has a beneficial role in the diagnostic work-up of gross or microscopic hematuria when standard evaluation results in equivocal or conflicting information from cystoscopy and imaging studies. In this patients case, the records documented a normal cystoscopy and normal computed tomography (CT) urogram which would not benefit statistically from Cxbladder testing based on the literature and current practice guidelines. Thus, CPT code 81479 (unlisted molecular pathology, Cxbladder) performed on 12/19/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 37-year-old female enrollee has requested reimbursement for gene testing performed on 1/19/15.  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 the pathology report was consistent with a follicular lesion of undetermined significance. This patient had this nodule for several years and patient was reluctant to incur in the risk of surgery.  Per the medical records, the size of nodule, age and gender increased the patients risk for malignancy.  Afirma testing was a valuable tool in this case.  It made the recommendation and decision to remove the tumor more certain.  Therefore, gene testing performed on 1/19/15 was likely to have been superior over other available modalities for 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  
The patient is a five-year-old male who was admitted for hospitalization for diagnostic evaluation 
and management of the abrupt onset of uncontrolled myoclonic seizures and ataxia. The patients 
parent has requested reimbursement for an inpatient stay from 3/2/22 through 3/5/22. 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 the submitted documentation supports the medical necessity of the 
services at issue. Alix and colleagues note that useful clinical information is obtained in most 
children in whom events are captured on video EEG telemetry. The onset of myoclonic seizures 
in children places them at risk of significant risk of serious injury as the seizures may occur without 
warning and frequently cause the child to fall. The differential diagnosis for myoclonic epilepsy 
in children is broad, ranging from myoclonic-astatic epilepsy to a number of genetic forms of 
progressive myoclonic epilepsy, some of which are eventually fatal. Myoclonic epilepsy can be 
very difficult to control, often requiring high doses of medication, introduction of the ketogenic 
diet, and occasionally the implantation of the vagus nerve stimulator or corpus callosotomy. In this 
case, the patient had an abrupt onset of uncontrolled mixed seizures, with generalized tonic-clonic 
seizures and frequent myoclonic seizures. The patients seizures were frequent and uncontrolled 
despite his being on an Keppra, an anticonvulsant. The records noted that at times the patient had 
multiple myoclonic seizures while on video EEG telemetry. He had also an abrupt onset of ataxia, 
which appeared to have been related to starting Keppra. In this clinical setting, given that an 
inpatient diagnostic workup including a spinal tap, MRI of the brain, and video EEG telemetry to 
capture the seizure type for differential diagnosis, allow assessment of true seizure frequency, and 
assess  response  to  treatment  was  required,  the  services  at  issue  were  medically  indicated. 
Therefore, an inpatient stay from 3/2/22 through 3/5/22 was medically necessary for the treatment 
of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 31-year-old female enrollee has requested authorization and coverage for exome sequence analysis (gene panel testing). The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition.The physician reviewer found that patient has had a lifelong neurologic disorder without specific diagnosis and has been termed cerebral palsy, but has atypical features including episodic hypotonia, and no history of birth anoxia.  Clinical neurogenetic assessment has raised the possibility of an undiagnosed genetic disorder, for which there could be prognostic and clinical value in making a more precise diagnosis.  The medical evidence supports consideration of whole exome sequencing in the clinical diagnostic assessment of a phenotypically affected individual when the phenotype or family history data strongly implicate a genetic etiology, but the phenotype does not correspond with a specific disorder for which a genetic test targeting a specific gene is available on a clinical basis.  This patient has a phenotype that may have a genetic basis, for which specific diagnosis could yield prognostic or therapeutic advantages.  Therefore, the requested exome sequence analysis (gene panel testing) is likely to be more efficacious than other modalities for evaluating this patient.  Based upon the information set forth above, the requested services are 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 46-year-old female enrollee has requested reimbursement for continuous positive airway pressure (CPAP) device provided on 1/3/18. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees obstructive sleep apnea. The physician reviewer found that current practice guidelines from the American Academy of Sleep Medicine (AASM) noted that OSA be treated as a chronic disease. In addition, Epstein and colleagues recommended that all patients with OSA should have ongoing, long-term management for their disorder. Patients on chronic therapy such as CPAP should have regular, ongoing follow-up to monitor adherence to therapy, side effects, development of medical complications related to OSA, and continued resolution of symptoms. In this case, the medical records provided demonstrate that the patient was diagnosed with OSA, was titrated on CPAP, and prescribed a CPAP for home use. Based on the current guidelines, CPAP is recommended as the first-line treatment for use in OSA. In this clinical setting, the CPAP device provided on 1/3/18 was medically necessary for treatment of this patients OSA. Based on the forgoing discussion, the device at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1 
 
A 52-year-old female enrollee has requested reimbursement for BCR-ABL gene rearrangement 
quantitative polymerase chain reaction (PCR) testing, BCR-ABL fluorescent in situ hybridization 
(FISH) performed on 11/21/22. The physician reviewer found that Myeloproliferative syndromes 
are clonal disorders that present as chronic myeloid leukemia (CML), chronic myelomonocytic 
leukemia (CMML), polycythemia vera, or essential thrombocythemia, or primary myelofibrosis. 
CMML has both myelodysplastic and myeloproliferative features but can also present with high 
monocyte counts (Orazi and Germing; Emanuel). CML is defined by the presence of the BCR-ABL 
rearrangement, whereas CMML has been associated with a distinct set of tyrosine kinase gene 
rearrangements and point mutations. This patients records document high monocyte counts in 
October 2022, which supports an indication for the BCR-ABL PCR and FISH testing performed in 
this patients case. All told, the BCR-ABL gene rearrangement quantitative PCR testing, BCR-ABL 
FISH performed on 11/21/22 was likely to be more beneficial for treatment of the patients 
medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a six-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 30 hours per week of applied behavioral analysis (ABA) therapy provided from 10/3/15 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees autism spectrum disorder (ASD).  The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. There is support in the medical literature demonstrating that ABA is effective for reducing aggression and self-injury. Mohammadzaheri and colleagues examined the use of ABA and pivotal response treatment in school age children with autism and disruptive behavior. The authors found these interventions to be very effective in decreasing maladaptive and disruptive behaviors even in school age children.  In this case, the patient has made slow, but steady improvements with ABA at 30 hours per week. He still has significant maladaptive behaviors specifically aggression and self-injury. There is no evidence that his behavior is at a point that a reduction in ABA is indicated.  Based on the support in the peer-reviewed literature, the request for 30 hours per week of ABA was and is medically necessary for treatment of the patients medical condition. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3  A 27-year-old female insured has requested reimbursement for the respiratory virus panel 
testing (CPT 87633, 87798, 87798-59) provided on 7/21/22. The Health Insurer has denied this 
request indicating that the services at issue were considered investigational for evaluation of the 
insureds respiratory illness and shortness of breath. The physician reviewer found that viral 
pathogens  are  often  the  most  common  cause  of  respiratory  infections  which  include 
rhinoviruses, respiratory syncytial virus, influenza virus, parainfluenza virus, adenovirus and 
coronaviruses. A review of the standard of care indicates that treatment is generally supportive 
and symptomatic. Further, antibiotics are rarely utilized, and antiviral treatment is recommended 
only for patients with symptoms who are at high risk for complications. A review of medical 
literature indicates that identifying the specific viral cause of an upper respiratory infection is not 
likely to change the approach to treatment. Several standard methods available for diagnosis 
include molecular methods, rapid tests, and microbiologic culturing. Influenza-specific assays 
may be indicated for patients presenting with fever and flu-like syndrome. Otherwise, viral 
polymerase chain reaction testing is generally not indicated. In this case, the patient presented 
with complaints of cough, shortness of breath and malaise. A review of the record establishes 
that the patient had typical symptoms of an upper respiratory tract infection. The patients vital 
signs were stable and the initial treatment included a nebulized breathing treatment that was 
effective to alleviate symptoms. The patient was also provided a diagnostic work-up which 
indicated a normal white blood cell (WBC) count and a normal chest x-ray. Overall, the respiratory 
viral panel testing was not expected to change the patients plan of care more than standard 
testing. Therefore, the respiratory virus panel testing (CPT 87633, 87798, 87798-59) provided on 
07/21/22  was  not  likely  to  have  been  more  beneficial  than  any  other  available  standard 
treatment for the evaluation of the patients condition.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 66-year-old male enrollee has requested reimbursement for the unlisted chemistry procedure (84999) Prometheus Anser testing performed on 12/22/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease.  The physician reviewer found the concept of following drug levels when using tumor necrosis factor (TNF)-alpha antibodies to provide personalized dosing has been around for many years. Following drug levels can keep a patient at a target level which translates into a higher probability of clinical benefit. This concept is based primarily on retrospective data which has demonstrated that, in general, higher trough levels correlate directly, and the presence of antibody correlates indirectly, with clinical efficacy. Knowledge of the drug and antibody level would therefore assist the provider in the decision to increase a drugs dose or perhaps switch to another class of biologics. However, this approach has not been shown to be superior to making empiric changes. There is a lack of controlled data which have identified the optimal drug level. A recent trial demonstrated this approach had no impact on clinical efficacy compared to empiric dose titration (Steenholdt, et al). Therefore, the unlisted chemistry procedure (84999) Prometheus Anser testing performed on 12/22/15 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: Experimental
Decision: Overturned

Summary Reviewer 2


A 53-year-old female enrollee has requested authorization and coverage for vascularized lymph node transfer (VLNT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the requested procedure is a sophisticated vascularized flap transfer and lymphaticovenous anastomoses with a microsurgical technique. The results documented in the medical literature show a statistically significantly improved functional outcome as a result of the procedure. Moreover, this procedure is specialized and cannot be recommended as routine treatment for all patients. The requested procedure is indicated for well-selected patients, such as in this patient with documented severe lymphedema. In addition, VLNT is likely to yield significant benefits for this patient. Therefore, in this clinical setting VLNT is 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 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: Overturned

Summary Reviewer 1

A 55-year-old male enrollee has requested authorization and coverage for the LINX lower esophageal sphincter augmentation device. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that in 2013, the U.S. Federal Drug Administration (FDA) approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate GERD, and a hiatal hernia less than 3 cm. This patient meets these specific criteria. Based upon a prospective study that included 44 patients, the mean total percent time pH less than 4 was reduced from 11.9% at baseline to 3.8% at three years (Lipham, et al). A recent study comparing the LINX procedure with laparoscopic fundoplication found that GERD patients had similar control of reflux symptoms after both LINX and fundoplication. The authors noted that the inabilities to belch and vomit were significantly fewer with LINX, along with a significantly lower incidence of severe gas-bloat symptoms (Reynolds, et al). Finally, five-year cohort data was published establishing the durability of the device. In a group of 85 patients, augmentation of the lower esophageal sphincter with a magnetic device provided significant and sustained control of reflux, with minimal side effects or complications. No new safety risks emerged over a five-year follow-up period (Ganz, et al). All told, the requested LINX lower esophageal sphincter augmentation device is 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 procedure 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.