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

Summary Reviewer 3

A 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma assay performed on 4/12/18. 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 there is a lack of support for the services at issue in this clinical setting. As the records do not document that the patient underwent a sentinel node procedure, it cannot be determined whether the patient had stage I/II/II disease. The proposed clinical utility of the DecisionDx-Melanoma assay applies to pathologically confirmed stage I/II/III. Therefore, DecisionDx-Melanoma assay was not likely to have been beneficial for this patients medical condition, as it has not been determined that he had the correct stage of disease due to the lack of lymph node staging. Thus, DecisionDx-Melanoma assay performed on 4/12/18 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

An 81-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 2/27/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the current medical evidence does not support the services at issue in this clinical setting. This patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. In sum, DecisionDx-Melanoma testing performed on 2/27/18 was not likely to have been superior over other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 17-year-old male enrollee has requested authorization and coverage for Nutropin. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees short stature. The physician reviewer found that the records provided for review document that this patient has been receiving GH therapy for GH deficiency. Based on current guidelines from the Lawson Wilkins Pediatric Endocrinology Society Drug and Therapeutics Committee and American Association of Clinical Endocrinologists, continuation of therapy is medically necessary until epiphyseal fusion and/or until growth velocity is less than 2 cm per year. Based on the report from the most recent examination by the patients provider in January 2016, the patient still has open epiphyses and continues to grow at a growth rate that is greater than 2 cm per year. Thus, the requested GH therapy with Nutropin is medically necessary for this patient. Based on the foregoing discussion, 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 3

The parent of a 14-year-old female enrollee has requested authorization and coverage for colon motility (manometric) study, minimum six hours continuous recording (including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed), with interpretation and report, procedure code 91117, and associated one day inpatient admission. The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollee, who has a history of bowel incontinence. The physician reviewer found that this patient has been diagnosed with Phelan-McDermid syndrome. Patients with this condition have a wide range of medical, intellectual and behavioral challenges. Gastrointestinal issues are common and include reflux, vomiting, diarrhea, constipation and hypotonia. Manometry studies help in understanding the pathophysiology of the defection disorders in these children. Studies have shown that surgical interventions in these patients, as guided by manometric findings, have led to improvement in patient outcome and quality of life. The requested services are an appropriate next step for this patient with intractable constipation and stool incontinence. Thus, colon motility (manometric) study, minimum six hours continuous recording (including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed), with interpretation and report, procedure code 91117, and associated one day inpatient admission are likely to be more effective than other methods of 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 22-year-old male enrollee has requested reimbursement for surgical treatment of femoroacetabular impingement syndrome performed on 12/23/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees hip pain.The physician reviewer found that surgical treatment of symptomatic femoroacetabular impingement aims to improve symptoms and potentially delay hip osteoarthritis and prevent the need for a possible total hip arthroplasty. Hip arthroscopy and open surgical hip dislocations are the two most common surgical approaches used for this condition.  The arthroscopic procedure avoids some of the complications of open surgery, but both approaches result in over 75% good to excellent results.  Femoroacetabular impingement may be of the cam or pincer-type, or it may be mixed as in this case.  Surgery is recommended when the degenerative changes are mild or absent, as in this case with documented failure of conservative treatment. The current medical literature indicates that arthroscopic surgery for femoroacetabular impingement has a known excellent outcome in the majority of individuals. Thus, surgical treatment of femoroacetabular impingement syndrome performed on 12/23/15 was likely to have been of greater benefit than other treatment alternatives. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 57-year-old male who presented with a prostate-specific antigen (PSA) of 7.0. The patient has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that there is a lack of support for the requested services in this clinical setting. The patientas history of hemochromatosis is not sufficient to support the use of proton beam therapy for his prostate cancer. There is a lack of strong medical evidence to suggest that treatment with proton beam therapy is associated with a clinical benefit compared to standard treatment. Furthermore, proton beam therapy has not been validated in a comparative randomized study to standard treatment with photons. Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Vapiwala and colleagues performed a multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer and compared groups receiving hypofractionated radiation proton therapy and intensity modulated radiation therapy with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, it found no difference in disease control between the two modalities. The American Society of Radiation Oncology (ASTRO) stated, aProton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry.a ASTRO notes that the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and intensity modulated radiation therapy technique. Therefore, the requested proton beam therapy is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 58-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Plan has denied this request indicating that the requested procedure is considered investigational for the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found the U.S. Food and Drug Administration (FDA) has approved the LINX Reflux Management System for the treatment of lower esophageal sphincter augmentation. The device is a ring made up of a series of magnets that have sufficient attraction to increase the lower esophageal sphincter (LES) closure pressure, but allow for food passage with swallowing. Reynolds and colleagues performed a study comparing the LINX procedure with laparoscopic fundoplication was performed which used propensity matching to compare groups. The authors found that GERD patients had similar control of reflux symptoms after both LINX and fundoplication. The inabilities to belch and vomit were significantly fewer with LINX, along with a significantly lower incidence of severe gas-bloat symptoms. In addition, a five-year cohort data was recently published establishing the durability of LINX. 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. Given the support cited above, the LINX procedure 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.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 34-year-old female enrollee has requested reimbursement for genetic testing for fragile X syndrome (CPT code 81423) provided on 6/28/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees pregnancy. The physician reviewer found that according to the American College of Obstetricians and Gynecologists (ACOG), screening for spinal muscular atrophy should be offered to all women who are considering pregnancy or are currently pregnant. However, the ACOG only recommends fragile X syndrome testing for patients with a family history of fragile X-related disorders or intellectual disability suggestive of fragile X syndrome and who are considering pregnancy or are currently pregnant or if a woman has unexplained ovarian insufficiency or failure or an elevated follicle-stimulating hormone level before age 40 years, fragile X carrier screening is recommended to determine whether she has an FMR1 premutation. In cases of this discordance, the patient should be referred to a genetics professional. However, the ACOG does not support an indication for genetic testing for fragile X syndrome in this clinical setting. For these reasons, the genetic testing for fragile X syndrome (CPT code 81423) provided on 6/28/17 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 47-year-old female enrollee has requested reimbursement and prospective authorization and coverage for pertuzumab injections from 8/18/15 forward. 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 pertuzumab has been shown to increase pathologic complete responses in patients with HER2 positive breast cancer.  Pertuzumab is recommended for neoadjuvant therapy for four to six cycles, and if not given in the neoadjuvant setting, may be given for four to six cycles as adjuvant therapy.  However, there is a lack of support for adjuvant therapy with pertuzumab in this clinical setting.  Therefore, pertuzumab injections from 8/18/15 forward were not and are not likely to be of greater benefit than other treatment options.  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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1 
 
A 27-year-old female insured has requested authorization and coverage for Besremi 500 mcg/mL 
syringe. A review of the record indicates the insured is currently pregnant and has a history of 
essential thrombocythemia. The Health Insurer indicates the requested treatment is considered 
investigational for the treatment of the insureds medical condition. Therefore, the Health Insurer 
has denied coverage for the requested treatment. This denial is the subject of this appeal and 
determination. The physician reviewer found that the records provided for review document that 
this patient presents with low-risk Janus kinase 2 (JAK2)-positive essential thrombocytosis. Per 
the provider, the patient does not have a prior history of thrombotic complications. The patient 
was started on Pegasys after she became pregnant. The patient has reportedly tolerated treatment 
with Pegasys other than injection site pain. The patients provider has recommended treatment 
with Besremi. However, The U.S. Food and Drug Administration (FDA) has not approved 
Besremi in the setting of essential thrombocytosis. Moreover, Besremi has not been listed on the 
National Comprehensive Cancer Network (NCCN) guideline as a recommended therapy option 
for patients with essential thrombocytosis. Therefore, the requested Besremi 500 mcg/mL 
syringe is not 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 58-year-old male enrollee has requested authorization and coverage for epidural steroid injections. 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 that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patients physical examination and lumbar magnetic resonance imaging (MRI) do not show evidence of lumbar radiculopathy/radiculitis.  The peer-reviewed medical literature provides evidence for epidural steroid injections in documented cases of nerve root compression or radiculitis.  The patients chronic pain condition is not consistent with such a diagnosis.  There is a lack of support for the requested services in this clinical setting.  All told, the requested epidural steroid injections are not medically indicated for the treatment of this patient.  Therefore, 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: Upheld

Summary Reviewer  
 
The patient is a 63-year-old male who has a history of back pain. The patient has requested 
authorization and coverage for MRI of the lumbar spine. The physician reviewer found that the 
submitted documentation fails to demonstrate the medical necessity of the requested services. 
According to the American College of Radiology (ACR), In  the  absence of  red  flags,  first-line  
treatment  for chronic  low back pain  remains conservative therapy  with  both pharmacologic 
and non-pharmacologic (e.g., exercise, remaining active) therapy. However, patients presenting 
with  subacute or  chronic low back pain,  with  or  without  radiculopathy,  who  have  failed  six  
weeks of  conservative therapy should be imaged if they are believed to be candidates for surgery 
or  intervention  or  if  diagnostic  uncertainty remains.  The goal of imaging is to identify potential 
actionable pain generators that could be targeted for intervention or surgery. The current 
documentation indicates that physical therapy was done in 2019, but the records do not 
document more recent failure of physical therapy. There is no documentation of a surgical 
consultation with plan for invasive therapy. The records do not document neurological deficits. 
Therefore, the requested MRI of the lumbar spine is not medically necessary for the evaluation 
of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer

The patient is a 55-year-old female with duplex documented right great saphenous vein reflux and a vein measuring greater than 6 mm at the saphenofemoral junction and further down the thigh. She has completed conservative measures and has had previous interventions. The patient has requested authorization and coverage for varicose vein surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. There is sufficient support for the requested services in this clinical setting. Despite prior interventions, this patient remains symptomatic. Additionally, the records document a prior course of conservative treatment. Per the records, her prior treatment included compression hose, elevation, exercise and Motrin. The medical evidence supports the requested services in this patients case. Thus, the requested varicose vein surgery is medically necessary for the treatment of this patient. Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 54-year-old female enrollee has requested reimbursement for inpatient hospitalization provided from 3/31/17 through 4/07/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who sustained injuries when she fell off a horse. The physician reviewer found that this patient presented status post a traumatic fall from a horse resulting in severe back pain. Clinical examination findings were consistent with imaging evidence of L1 and L3 acute compression fractures. She had severe pain that was not controlled with oral medications. She was admitted for inpatient care for pain control and observation on 3/31/17. She was placed on bed rest with bracing ordered. She continued to require intravenous medication due to inadequate relief with oral medications. She was very limited in her activity due to severe pain. Given the failure of closed treatment with bracing and continued severe pain with associated functional limitations, she underwent L1 and L3 vertebroplasty on 4/04/17. Following this procedure, she was able to ambulate with physical therapy, and oral pain medications provided adequate control as of 4/07/17. She was discharged to home on 4/07/17 with home health services. Evidence-based medical guidelines support hospitalization for parental narcotics and inability to manage basic activities of daily living at home, and additionally support a three-day best practice length of stay following vertebroplasty. Continued inpatient stay is supported until acceptable patient status for the next level of care is achieved, including pain is adequately managed on oral medications, and activity levels are at baseline or acceptable. Therefore, inpatient hospitalization provided from 3/31/17 through 4/07/17 was medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 68-year-old male enrollee has requested reimbursement for the positron emission tomography (PET) scan performed on 2/3/15. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for evaluation of the enrollees cognitive impairments, neuropsychiatric symptoms and parkinsonian features. The physician reviewer found that although a PET scan is not indicated for every patient with progressive cognitive symptoms, it is useful and beneficial for a subset of patients suspected to have FTD versus AD. According to Foster and colleagues The addition of FDG-PET [positron emission tomography with 18F fluorodeoxyglucose] to clinical summaries increased diagnostic accuracy and confidence for both AD and FTD. It was particularly helpful when raters were uncertain in their clinical diagnosis. In this case, the patient was documented to have progressive cognitive decline with abnormal neuropsychological testing and no clear etiology determined by traditional testing. In cases such as this, it is essential to obtain the correct diagnosis to implement the proper treatment and avoid unnecessary treatments that may produce significant side effects. A PET scan is a reasonable medical approach to determine diagnosis and implement the proper therapy as AD and FTD are treated with different medical approaches. Therefore, the PET scan performed on 2/3/15 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 diagnostic procedure 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.