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

Summary Reviewer 2


A 60-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 8/04/16.  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 that the current medical literature supports the service at issue in this patients case.  Per Skaane and colleague, 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 integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Therefore, breast tomosynthesis performed on 8/04/16 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: Overturned

Summary Reviewer 3 
A 49-year-old female insured has requested authorization and coverage for thermal destruction of 
intraosseous basivertebral nerve including all imaging guidance; first two vertebral bodies, lumbar 
(CPT 64628). The insureds symptoms are having a significant impact on activities of daily living 
such as household chores, leisure activities, sleeping, and work. Medications have included 
acetaminophen,  Celebrex,  meloxicam,  naproxen,  and  muscle  relaxants.  The  Health  Insurer 
indicates the requested services are considered investigational for the treatment of the insureds 
medical condition. Therefore, the Health Plan has denied coverage for the requested treatment. 
This denial is the subject of this appeal and determination. The physician reviewer found that per 
the peer-reviewed medical literature, basivertebral nerve ablation is a safe and effective treatment 
modality  for  well-selected  patients  with  chronic  low  back  pain  that  has  failed  adequate 
conservative measures. One study from Khalil and colleagues study was terminated prematurely 
due to the clear superiority of Intracept, allowing cross-over of control arm patients to the Intracept 
arm. Fischgrund and colleagues found that patients treated with basivertebral nerve ablation 
experienced significant improvement in pain and function out to a mean of 6.4 years, confirming 
the long-term effectiveness and durability of basivertebral nerve ablation. This patient presents 
with a long history of chronic severe low back pain with severe limitations of activities of daily 
living. Therapeutic attempts to manage the patients symptoms have included multiple analgesic 
medications, radiofrequency ablation of medial branch nerves, physical therapy, trigger point 
injections, and acupuncture. The patients imaging studies support treatment with minimally 
invasive  basivertebral  nerve  ablation.  The  patients  records  do  not  document  any  signs  or 
symptoms of severe radiculopathy or myelopathy, and there are no imaging findings to warrant 
treatment with disc replacement or fusion. The patients presentation along with MRI findings 
meet the criteria for treatment with basivertebral nerve ablation. For these reasons, the requested 
thermal destruction of the intraosseous basivertebral nerve including all imaging guidance; first  two vertebral bodies, lumbar (CPT 64628) is likely to be more beneficial for the treatment of the 
patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 59-year-old female enrollee has requested authorization and coverage for Toujeo SoloStar 300 units/mL. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees type 2 diabetes with hyperglycemia. The physician reviewer found this patient is not intolerant of Lantus and has not been treated with Levemir, as recommended by the Health Insurer. While the control was reportedly better on the Toujeo SoloStar, the records do not adequately specify what else has changed with the insulin and the patients treatment plan. Further, the documentation does not indicate the patient was having low A1c levels. Overall, the relevant medical studies indicate that Toujeo SoloStar is as good in terms of A1c control as Lantus, but not superior to Lantus. All told, the records do not support the medical necessity of the requested Toujeo SoloStar 300 units/mL for treatment of this patients medical condition.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 48-year-old male enrollee has requested reimbursement for polymerase chain reaction (PCR) testing performed on 7/15/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the PCR testing performed on 7/15/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the patient presented with non-specific complaints and few risk factors for Lyme disease. PCR testing is not a recommended testing method based on Centers for Disease Control and Prevention (CDC) guidelines. The recommendation for treatment and diagnosis of Lyme include Elisa and Western blot testing (Wormser, et al). For these reasons, the testing at issue was not indicated for evaluation of the patients medical condition.  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: Upheld

Summary Reviewer

The patient is a seven-year-old male with a history of constitutional delay of growth and development. The patient was born at 30 weeks gestational age after a pregnancy complicated by eclampsia, and emergency cesarean section secondary to fetal distress and maternal hypertension. The patients birth weight was three pounds two ounces. On 11/8/17, the provider noted that the patients bone age on 10/12/16 showed a bone age of four years six months, at a chronological age of six years two months. A later bone age study in November 2017, was five years six months, at a chronological age of seven years three months. The height is noted to be below the 1.2 percentile for age. The provider has recommended growth hormone therapy on the basis of idiopathic short stature. His parent has requested authorization and coverage for somatropin (Norditropin). The Health Insurer has denied this request indicating that the requested medication is not medically necessary. The patients growth velocity in November 2017 was stated as being an annualized 6.4 cm per year. His height standard deviation score is -2.4, putting him at the 0.9%. Using his last bone age the patients predicted adult height is approximately five feet, eight to nine inches. The genetic target for this patient is therefore likely five feet 9.25 inches, +/-4 inches. The normal laboratory data, bone age delay, and last calculated height velocity indicate that he has constitutional delay. However, exogenous growth hormone is not likely to be present so long as the patient maintains a normal height velocity. All told, the requested somatropin (Norditropin) 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: Experimental
Decision: Upheld

Summary Reviewer 1

A 34-year-old female enrollee has requested reimbursement for the gene test provided on 3/17/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for heart disease. The physician reviewer found that this patient presents with no reported history of cardiovascular disease. Her BMI is elevated and she has a history of vitamin D deficiency and hypothyroidism with no reported history of diabetes with a normal fasting glucose. Her baseline standard lipid profile shows a total cholesterol under 200 and mildly low high density lipoprotein (HDL), normal non-HDL cholesterol and triglycerides, with a borderline high low density lipoprotein (LDL) cholesterol of 140. She is not a candidate for consideration of statin therapy based on current risk parameters and the current lipid profile (Goff, et al; Stone, et al). There is no significant data that in a patient with this low standard risk profile, and in the absence of established cardiovascular disease or other significant risk factors for coronary artery disease at her age, that advanced lipid profile testing will add further clinically actionable information to the cardiovascular risk assessment or change the treatment strategy (Greenland, et al; Goff, et al). Thus, the gene test provided on 3/17/16 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 1


A 60-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 9/22/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer.   The physician reviewer found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed on 9/22/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 46-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the medical evidence supports the requested services in this setting. This patient has already failed APAP therapy and is not an optimal candidate for oral appliance therapy due to the severity of his
obstructive sleep apnea. The alternative, no treatment, would lead to potential harms, such as increased medical c-morbidities including hypertension, diabetes, congestive heart failure, myocardial infarction, and stroke. There is sufficient evidence in the peer-reviewed literature to support the safety, efficacy, and long-term outcome in the treatment of obstructive sleep apnea with hypoglossal nerve stimulation or Inspire airway stimulation. Multiple published studies show clinically significant decreases in observed mean apnea-hypopnea index and Epworth Sleepiness Scale score, combined with improvements in quality-of-life scales. There is ample evidence supporting the safety, efficacy, and long-term outcome in the treatment of obstructive sleep apnea with the Inspire device. Therefore, hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 43-year-old female enrollee has requested reimbursement for the blood testing provided on 1/17/17. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cardiovascular risk. The physician reviewer found that the records indicate that this patient has no history of cardiovascular disease nor any significant risk factors for cardiovascular disease other than an elevated body mass index (BMI). There is no history of hypertension, diabetes, cigarette smoking, or family history of early cardiovascular disease. She has a negative risk factor in that her HDL cholesterol is above 60 and her LDL cholesterol is only mildly above the optimal range. The patients 10-year cardiovascular risk is very low (0.4%) based on the American Heart Association (AHA) and American College of Cardiology (Goff, et al; Stone, et al). In this clinical instance, given the low 10-year cardiovascular risk using traditional clinical and laboratory criteria, with no clinical cardiovascular risk factors, additional advanced risk factor testing to assess lipid particle number and size is not indicated in this clinical situation and would not change treatment recommendations (Mora, et al). Given these findings, the blood testing provided on 1/17/17 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: Upheld

Summary Reviewer 2

A 37-year-old female has requested authorization and coverage for Gammagard liquid 10% vial. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollee, who has a history of recurrent pregnancy loss. The physician reviewer found this patient has a complicated medical and obstetric history.  She has had a thorough work-up and multiple treatment modalities. While intravenous immunoglobulin (IVIG) seems to be an emerging and promising treatment option, the superior effectiveness of this treatment has not been established at this time. As noted in the American College of Obstetricians and Gynecologists Practice Bulletin Number 132, other therapies that have been suggested for treatment of pregnant women with antiphospholipid syndrome include corticosteroids and intravenous immunoglobulin.  However, the authors noted that because the efficacy of IVIG has not been proved in appropriately designed studies, its use is not recommended. In sum, Gammagard liquid 10% vial is not likely to be more beneficial than other available treatment methods.  Based upon the information set forth above, the requested medication is 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 


An 18-year-old male enrollee has requested reimbursement for residential treatment center (RTC) services provided from 2/1/15 through 3/24/15 and intensive outpatient program (IOP) services provided from 3/25/15 through 9/25/15. 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 that the RTC services provided from 2/1/15 through 3/24/15 and IOP services from 3/25/15 through 9/25/15 were medically necessary for treatment of the patients medical condition. The patients therapist recommended treatment at a residential facility due to increasing self-harm and suicidal ideation. The patient was initially admitted to the RTC level of care and then stepped down to IOP after he successfully completed each step. The services at issue were medically necessary for the development of strong bonds, therapeutic relationships and modeling types of behavior from which the patient himself can learn and emulate. In addition, the services provided were consistent and beneficial for treatment of the patients medical condition. Given the above, the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1
A 61-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/19/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee who presented for a breast examination.  The physician reviewer found that there is evidence based support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two-dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two-dimensional protocol was likely to have been more effective than had her examination been performed using two-dimensional imaging alone. Based upon the information set forth above, the service at issue was likely to have been 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 1


A 46-year-old male enrollee has requested reimbursement for the gastrointestinal (GI) effects comprehensive profile stool testing performed on 1/10/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the GI effects comprehensive profile stool testing performed on 1/10/16 was not likely to be more effective for this patient than other available options. Recommendations for the evaluation and management of irritable bowel syndrome do not support the approach prescribed for this patient. For example, a fecal calprotectin is part of the battery of tests included in the comprehensive stool analysis. This test would be potentially useful if the patient was undergoing an initial work-up. However, he already had an endoscopic work-up documenting that he does not have colitis. Given the above, the testing at issue 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: Upheld

Summary Reviewer 3

A 66-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Expression Assay provided on 10/12/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the DecisionDx-Melanoma Gene Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma Gene Assay has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Overall, there is a lack of published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx-Melanoma Gene Assay provided on 10/12/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was 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: Upheld

Summary Reviewer 1


A 64-year-old female enrollee has requested reimbursement and prospective authorization and coverage for proton beam radiation. The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees medical condition. The physician reviewer found Proton beam radiation was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The use of proton therapy is an accepted radiation technology that has proven efficacy and tolerability. For multiple myeloma, low doses are used to achieve palliation. IMRT and/or proton therapy can allow for better dose conformality of complex shaped targets. However, there is a lack of support for the use of proton therapy over IMRT when delivering such low doses. In this case, the actual radiation planning records are not provided, but the dose exposure of the right eye with IMRT is a mean of 23 Gy and the maximum dose recorded for all other structures are less than 12 Gy with IMRT.  Based on the documentation submitted for review both IMRT and proton beam appear to result in excellent coverage of the tumor with similar toxicity risks. Proton therapy will almost always reduce dose to surrounding normal tissues. Simply demonstrating that proton therapy reduces the dose to some normal tissues does not necessarily demonstrate that it is superior to IMRT.  Thus, proton therapy is not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were not and 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.