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

Summary Reviewer 1

A 60-year-old male enrollee has requested reimbursement for Oncotype DX prostate cancer assay (CPT code 84999) testing provided on 4/11/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees elevated prostate-specific antigen (PSA). The physician reviewer found that Oncotype DX prostate cancer testing provides valuable information to help the patient and provider to make a decision whether to provide watchful waiting or proceed with surgery or radiation therapy. The Oncotype DX is clinically indicated to guide management of the patients prostate cancer and is the standard of care in this patient population. All told, the Oncotype DX prostate cancer assay (CPT 84999) testing performed on 4/11/16 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 32-year-old female enrollee has requested authorization and coverage for Gamunex-C. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that the standard treatment of small fiber neuropathy is dependent on the underlying etiology as well as treatment of associated neuropathic pain, which can include several different classes of
medications. In small fiber neuropathy, current neuropathic pain treatment options are generally insufficient to relieve the pain substantially. Small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions. Intravenous immunoglobulin (IVIG) is a first-line treatment for immune-mediated neuropathies, such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy.
Erythromelalgia is a rare disorder that is characterized by erythematous, warm, painful extremities, which is often precipitated by cold conditions. The pathophysiology of erythromelalgia is incompletely understood. In a case study by Moody and colleagues, a patient with seronegative polyarthritis presented with a six-year history of erythromelalgia with recurrent bouts of painful erythema and triggered by minor trauma. Several medical therapies provided limited and inconsistent relief of her symptoms over many years. Treatment with intravenous immunoglobulin significantly decreased the frequency and severity of her symptoms. In this case, the patient has debilitating small fiber polyneuropathy with laboratory evidence of autoimmunity as well as clinical symptoms consistent with erythromelalgia. She has tried and failed conventional medical therapy. Based on the current medical evidence, patients with autoimmune small fiber neuropathy and erythromelalgia may improve clinically with intravenous immunoglobulin. Therefore, Gamunex-C is likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 53-year-old female enrollee has requested authorization and coverage for a powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), including microprocessor, sensors, all components and accessories, custom fabricated. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that a review of the literature reveals that there are few studies on the myoelectric elbow-wrist-hand orthosis, and the outcomes of the studies are inconsistent. The literature reveals that further studies with larger numbers of participants are needed that show consistent improvements in relevant outcome measures. Additionally, the studies performed were inconsistent with variations between the trials in the intensity, duration, and amount of training; type of treatment; participant characteristics; and measurements used. A literature review by Carey evaluating the differences in myoelectric and body-powered upper limb prostheses revealed conflicting evidence in terms of the relative functional performance of body-powered and myoelectric prostheses. The authors noted, aBody-powered prostheses have been shown to have advantages in durability, training time, frequency of adjustment, maintenance, and feedback; however, they could still benefit from improvements of control. Myoelectric prostheses have been shown to improve cosmesis and phantom-limb pain and are more accepted for light intensity work.a The authors reported that the current evidence is insufficient to conclude that either system provides a significant general advantage. Additionally, this study indicates that there is a lack of empirical evidence regarding functional differences in upper-limb prostheses. McCabe and colleagues indicated that a small retrospective chronic stroke study did reveal gains made on a measure of upper limb motor control. This study was limited by inconsistent timing of testing and variability in treatment dose. The authors noted that additional measurements across multiple domains are necessary to further elucidate how the device impacts patient care and functional performance. All told, the requested powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), including microprocessor, sensors, all components and accessories, custom fabricated is not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer

The patient is a 59-year-old male with a history of obstructive sleep apnea (OSA). A home sleep study on 9/29/16 revealed an obstructive apnea index of 1.5 and a hypopnea index of 1.5 with a total apnea/hypopnea index (AHI) score of 2.9, and a supine AHI score of 0.0. A dental device did not alleviate the patients sleep apnea or snoring. A second home sleep study on 4/10/17 demonstrated a rise in both an obstructive apnea index of 2.9 and a hypopnea index of 10.2 with a total AHI score of 13.1. The results revealed a supine AHI of 24.6. The patient was provided with an oral appliance. The patient has requested reimbursement for an oral appliance provided on 12/6/16. The Health Insurer has denied this request indicating that the device at issue was not medically necessary. Consistent with the recommendations from the American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM), the oral appliance provided to this patient with OSA was medically necessary. The patients polysomnogram on 4/12/17 revealed findings consistent with moderate-to-severe OSA syndrome. Moreover, the results revealed a supine AHI of 24.6. As the patient was found to have moderate-to-severe supine and positional OSA syndrome, the oral appliance provided on 12/6/16 was medically necessary for treatment of this patients medical condition.  Based on the foregoing discussion, the device at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 45-year-old female who had been trying to conceive for greater than six months, without success. Her work-up was suggestive of diminished ovarian reserve. The patient has requested reimbursement for infertility services provided from 2/08/19 through 2/11/19. The physician reviewer found that infertility is defined as a condition in an individual who is unable to conceive or produce conception during a period of six months in a female over the age of 35 years. In this case, in vitro fertilization would not be considered medically necessary due to its low likelihood to achieve pregnancy in a then 44-year-old patient. Increasing maternal age negatively impacts the live birth rate after embryo transfer when the patients own eggs are used. This effect is particularly pronounced for women age 40 and greater. After age 43, the Centers for Disease Control and Prevention indicates that the probability of live birth is 5.7 percent. Thus, many clinics will not provide in vitro fertilization to women using autologous oocytes after the 44th birthday when the live birth rate declines further to 4.6 percent. Thus, infertility services provided from 2/08/19 through 2/11/19 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 31-year-old male enrollee has requested reimbursement for mental health outpatient services provided at a frequency of one time per week from 12/20/18 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 submitted documentation supports the medical necessity of the services at issue. The medical records indicate that the patient has been receiving therapy on outpatient basis. The progress notes do not describe suicidal or homicidal ideation. He continues to have anxiety as well as functional impairment due to his generalized anxiety disorder. Functional impairment must be present in order for a set of symptoms to classify as a mental illness. The patient has anxiety symptoms that have continued over several months, and the progress notes indicate episodes of increased anxiety.  He has been receiving therapy, but his symptoms have shown only mild improvement as evidenced by continued anxious affect and symptom report. The medical evidence supports the services at issue in this clinical setting. Therefore, mental health outpatient services provided from 12/20/18 forward were and are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2
A 57-year-old female requested reimbursement for magnetic resonance imaging (MRI) provided on 9/2/16.The Health Insurer has denied this request and reported that the service at issue was  considered investigational for evaluation of the enrollee who has a history of breast cysts. The physician reviewer found that according to the American College of Radiology appropriateness criteria for breast MRI, there is no data to support the use of breast MRI in the evaluation of breast pain as it does not meet the risk/benefit criteria. Cyclical pain is almost always due to hormonal fluctuation. The appropriate imaging examination for breast pain is mammography with possible ultrasound. Regarding the use of screening MRI for high risk patients, it is recommended for those patients with BRCA genetic mutations and their untested first degree relatives, women with additional genetic syndromes which increase the risk of breast cancer, women with a lifetime risk of greater than 20% and women who have received radiation therapy to the chest between the ages of 10 and 30. According to these criteria, this patient does not qualify for high risk MRI screening, as her lifetime risk is less than 20%. The patient has documented breast cysts on ultrasound. As such, MRI is not indicated for further evaluation of cysts. Diagnostic mammography with ultrasound is the appropriate imaging test for further evaluation of breast lumps/cysts. Therefore, in this patients case, MRI performed on 9/2/16 was not likely to have been more beneficial for the evaluation of this patients condition than the available standard imaging.Based upon the information set forth above, the service 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 3

A 57-year-old female enrollee has requested reimbursement for comprehensive cancer genomic panel provided on 5/9/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees rectal carcinoma. The physician reviewer found that to demonstrate clinical utility of panel testing for somatic genomic alterations, such as FoundationOne, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with the standard of care. The available literature on clinical utility consists of a small number of uncontrolled studies, and nonrandomized controlled trials that use imperfect comparators. This evidence is insufficient to make conclusions on clinical utility. All told, the comprehensive cancer genomic panel provided on 5/9/17 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 3

A 61-year-old male enrollee has requested reimbursement for gene expression profiling performed on 5/10/19. 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 there is a lack of support for the services at issue in this clinical setting. The patients risk for bladder cancer and prior history are unknown. The test is designed to detect bladder cancer and is a surveillance test that is proposed to be an adjunct to cystoscopy to rule out bladder cancer in patients with increased risk. In this patients case, the stage is unknown. At this time, the CxBladder gene expression test does not appear to be a standard of medical care. Medical evidence does not support its routine use. Thus, gene expression profiling performed on 5/10/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3 
A 31-year-old female has requested reimbursement for lab tests that measure the levels of 
medication, adalimumab (ADA) performed on 8/1/22. The Health Insurer has denied this request 
indicating that the testing at issue was considered investigational for evaluation of the insureds 
ulcerative colitis. The physician reviewer found that on review of the current peer-reviewed 
medical literature, the drug assay testing for ADA performed on 8/1/22 was likely to be more 
beneficial for the evaluation of this patient than any available standard therapy. The drug testing 
performed was reactive drug monitoring since the test was recommended in response to the 
patients symptoms of ulcerative colitis. The most recent national guideline from the AGA 
specifically  endorses  reactive  drug  monitoring  in  this  clinical  setting  when  the  patient  has 
symptoms while on anti-TNF agents such as ADA (Feuerstein, et al.). The AGA guidelines cite 
data that has shown that reactive drug monitoring is more beneficial than standard therapy 
including  change of  drug therapy without the drug  assay  and  is  supported with  consensus 
agreement among experts (Feuerstein, et al.; Papamichael, et al.). Thus, the lab tests that measure 
the levels of adalimumab performed on 8/1/22 was likely more beneficial for evaluation of the 
patient than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
 
The parent of a 16-year-old male enrollee has requested reimbursement for immunoassay for 
analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise 
specified and adalimumab on 8/6/21. The Health Insurer has denied this request indicating that the 
service and medication at issue were investigational for the treatment of the enrollees ulcerative 
colitis. The physician reviewer found that the current medical literature suggests that if there is 
evidence of ongoing inflammation or active disease while on biologic therapy, testing of drug 
antibodies and levels are useful in determining whether or not to make a drug change. In a 
randomized controlled trial, Peyrin-Biroulet and colleagues report that Entyvio is more effective 
than adalimumab in controlling severe ulcerative colitis. In this case, immunoassay or antibody 
testing, not infectious agent otherwise specified, is more beneficial than the standard testing 
including testing for C-reactive protein, or fecal calprotectin, or an elevated platelets count. The 
results may inform the changing of a biologic medication from an anti-tumor necrosis factor (TNF) 
agent, such as Humira, to a different class of biologic medication, such as Entyvio, an alpha-4 
integrin receptor blocker that has been shown to be beneficial in this clinical setting. Therefore, 
immunoassay  for  analyte  other  than  infectious  agent  antibody  or  infectious  agent  antigen; 
quantitative, not otherwise specified was likely to have been more beneficial for treatment of the 
patient's condition than any available standard therapy. However, adalimumab on 8/6/21 was not 
likely to have been more beneficial for treatment of the patient's condition than any available 
standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3 
A 44-year-old male enrollee has requested reimbursement for nasopharyngoscopy, surgical, with 
dilation of eustachian tube (i.e. balloon dilation); bilateral on 7/6/21. The Health Insurer has denied 
this request and reported that the service at issue was investigational for the treatment of the 
enrollees bilateral chronic eustachian tube dysfunction. The physician reviewer found that the current 
medical literature supports the use of eustachian tube balloon dilation in the setting of chronic 
otitis media and eustachian tube dysfunction. The symptoms of obstructive eustachian tube 
dysfunction include aural fullness, pressure, hearing loss, and otalgia. Eustachian tube dysfunction 
is typically transient. For persistent eustachian tube dysfunction, nonsurgical medical management 
consisting of nasal steroid spray or oral steroid, nasal sprays, or pressure equalization maneuvers 
may suffice. Surgical management may consist of the placement of ear tubes in select cases, along 
with eustachian tube dilation when needed. Once extrinsic causes of eustachian tube dysfunction 
have been ruled out, and other common causes such as allergies, sinusitis, and laryngopharyngeal 
reflux have been managed, eustachian tube dilation may be of significant benefit. In a systematic 
review of eustachian tube balloon dilation for the treatment of eustachian tube dysfunction, 
Froehlich and colleagues reported clinically significant improvement in both subjective and 
objective criteria. In a study to assess balloon dilation of the eustachian tube with eustachian tube 
balloon catheter in conjunction with medical management, Poe and colleagues concluded that the 
study demonstrated the superiority of balloon dilation of the eustachian tube with balloon catheter 
in addition to medical management over medical management alone with nasal and oral steroids 
in the treatment of eustachian tube dilatory dysfunction in adults. Wang and colleagues report that 
balloon dilation results in significant improvement of eustachian tube dysfunction over newer 
techniques such as laser tuboplasty. In this case, notes dated 9/11/20 reported that the patient 
underwent medical management with a nasal steroid spray and an oral antihistamine. When 
medical management failed, the patient underwent the more conservative procedure of placement 
of ear tubes. However, the patient continued to have symptoms and underwent eustachian tube 
dilation. In this clinical setting, the service at issue was likely to have been more beneficial than 
standard  medical  management,  ear  tube  placements,  and  laser  tuboplasty.  Therefore, 
nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e. balloon dilation); bilateral on 
7/6/21 was likely to have been more beneficial for treatment of the patients condition than any 
available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 63-year-old female enrollee has requested authorization and coverage for acute rehabilitation admission. 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 submitted documentation supports the requested services in this clinical setting. This patient has been diagnosed with a stroke secondary to a subarachnoid hemorrhage affecting the left frontoparietal and temporal region, resulting in aphasia and right-sided paresis. The patient is right-sided dominant and is therefore limited from performing activities of daily living. She is likely to benefit from speech therapy as well as occupational and physical therapy services that would be provided in a rehabilitation facility. It has become the standard of care to refer patients who experience a stroke to a rehabilitation facility. Therefore, the requested acute rehabilitation admission is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 60-year-old female enrollee has requested authorization and coverage for Xifaxan 500 mg. 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 patient had small intestinal bacterial overgrowth. Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. The medication has been shown to have greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones. Results are sustained for several weeks after treatment. Moraru and colleagues performed a prospective trial of patients with irritable bowel syndrome and small intestinal bacterial overgrowth. The authors found that 86% responded to Xifaxan, and symptoms were reduced as well. Xifaxan is effective for the treatment of constipation-predominant irritable bowel syndrome. In this case, while antispasmodic medications may address irritable bowel syndrome, they would not be expected to improve small intestinal bacterial overgrowth. Anti-diarrheal medications would not be appropriate in the use of constipation. Therefore, the use of Xifaxan 550 mg three times daily for 14 days is supported as medically necessary for the treatment of this patients small intestinal bacterial overgrowth in the setting of irritable bowel syndrome.