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

Summary Reviewer 2 
 
The  parent  of  a  13-year-old  female  enrollee  has  requested  reimbursement  for  needle 
electromyography (EMG) of anal or urethral sphincter, any technique; needle electromyography, 
each extremity; and electroencephalogram performed on 6/10/20. The Health Insurer has denied 
this request and reported that the services at issue were investigational for the treatment of the 
enrollees medical condition. The physician reviewer found that there is sufficient support for the 
services at issue in this clinical setting. In the article by Levin and colleagues, intraoperative neural 
monitoring for pediatric scoliosis correction is described as the standard of care. Buckwalter and 
colleagues noted that not only does intraoperative neural monitoring identify complications in a 
relatively  high  proportion  of  patients,  but  it  also  allows  for  corrective  action  to  prevent 
permanent neurologic injury. The neuromonitoring was standard of care in this patients case. 
Therefore, needle electromyography (EMG) of anal or urethral sphincter, any technique; needle 
electromyography, each extremity; and electroencephalogram performed on 6/10/20 was likely 
to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 37-year-old female enrollee has requested authorization and coverage for Remicade injections 100 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 this patient has moderate to severe Crohns disease based on extensive (orofacial and bowel) involvement. Per American Gastroenterological Association guidelines for therapy of moderate to severe Crohns disease, immunosuppressants such as azathioprine, 6-mercaptopurine, and methotrexate are not recommended as primary monotherapy, and tumor necrosis factor (TNF) inhibitors such as Remicade are recommended. American College of Gastroenterology guidelines also do not recommend immunosuppressants or methotrexate as primary monotherapy for the induction of remission of Crohns disease. In this case, the patient is unlikely to respond to conventional alternatives such as immunosuppressants, corticosteroids, and 5-aminosalicylate therapy, and she is at risk for additional Crohns disease complications such as fistula, stricture, hospitalization, and the need for surgery if induction and maintenance of remission is not effective. Therefore, Remicade injections 100 mg are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 48-year-old female has requested reimbursement for genotyping for CYP2D6 polymorphism performed on 7/10/14.  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 patients with hormone receptor positive breast cancer usually receive some pharmacologic therapy to inhibit the estrogen induced growth of the cancer.  The interventions differ for patients that are premenopausal and postmenopausal.  Tamoxifen is the preferred agent in premenopausal women whereas aromatase inhibitors are preferred in postmenopausal patients.  There is sufficient support for the services at issue in this clinical setting.  Saladores and colleagues performed a study of 587 premenopausal women and analyzed CYP2D6 genotypes and found that increased CYP2D6 activity correlated with improved disease-free survival.  In the event that tamoxifen was not a suitable anti-estrogen therapy for this patient, there were alternatives.  Based on the current medical literature, CYP2D6 genotyping is supported especially in premenopausal patients.  Thus, genotyping for CYP2D6 polymorphism performed on 7/10/14 was likely to have been more efficacious than other options 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: Experimental
Decision: Upheld

Summary Reviewer 3

A 36-year-old male enrollee has requested reimbursement for an implantable ambulatory event monitor provided on 12/28/17. The Health Insurer has denied this request indicating that the device at issue was considered investigational for evaluation of the enrollee, who reported palpitations. The physician reviewer found that the patient is a 36-year-old male with a history of hypertension and diabetes. The records noted a history of intermittent palpitations. An echocardiogram performed on 11/20/17 revealed normal left ventricular systolic function.  A 30-day event monitor reported one episode of atrial fibrillation lasting 30 seconds which was associated with palpitations.  Anticoagulation was not started at that time. An implantable loop recorder was placed on 12/28/17 to help determine burden of atrial fibrillation in order to help guide treatment. The patient has requested reimbursement for an implantable ambulatory event monitor provided on 12/28/17. The Health Insurer has denied this request and reported that the device at issue was investigational for the evaluation of this patient. In this case, the records documented palpitations which were determined to be due to atrial fibrillation by external event monitoring.  In this circumstance, if further monitoring for recurrent atrial fibrillation were thought to be necessary, then additional external event monitors that are either patient activated or auto-triggered should be sufficient as an initial step in identifying atrial fibrillation. There is no documentation to indicate the patient is unable to manage external monitoring devices or that these have been tried and failed. In this setting, recurrent atrial fibrillation could be adequately identified using a combination of symptoms and additional external event monitors, if needed. The implantation of a loop recorder in this circumstance has not been demonstrated to improve cardiac outcome and is not recommended in current guidelines. Thus, the implantable ambulatory event monitor provided on 12/28/17 was not likely to have been more efficacious than other methods of evaluating this patient. Based upon the information set forth above, the device 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 36-year-old female enrollee has requested reimbursement for polymerase chain reaction testing for bacterial vaginosis provided on 5/09/19. 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 Polymerase chain reaction (PCR) testing has been compared to traditional clinical testing for vaginitis. The literature supports the use of PCR testing because it has resulted in significantly higher sensitivity and negative predictive value than clinician diagnosis or in clinic testing. The test may also be superior for detecting more than one cause for vaginitis. PCR testing is a means of accurate detection that allows for appropriate treatment, and it is commonly used test in clinical practice. The records noted that the patient presented for a postpartum examination. During the postpartum period, it is especially difficult to make an accurate diagnosis of vaginal complaints. Missing an infection could lead to a serious postpartum complication. Thus, PCR testing for bacterial vaginosis performed on 5/09/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 64-year-old male enrollee has requested authorization and coverage for cetuximab (Erbitux) to be given in conjunction with FOLFIRI. The Health Insurer has denied this request and reported that the requested medication regimen is investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient has a very poor prognosis disease, a gastroesophageal junction cancer with regional metastases and progression on standard multi-agent chemotherapy. His tumor was submitted for mutational analysis. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Von Hoff and colleagues performed a pilot study of 86 patients, and the progression-free survival on regimen selected by molecular profiling was compared to progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. In this case, the analysis revealed marked amplification of the EGFR gene. The EGFRs have multiple oncogenic roles in gastroesophageal junction tumors. In this patients case, the oncologist has recommended FOLFIRI in combination with cetuximab. There is significant evidence that cetuximab can lead to a durable response in patients with EGFR amplification. Therefore, cetuximab (Erbitux) to be given in conjunction with FOLFIRI is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 32-year-old female enrollee has requested reimbursement for laboratory testing performed on 6/26/19. 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 when performing thrombophilia screening, while the probability of a positive assay is higher in patients with a history of thrombus, the information provided does not help to inform future management. Various professional organizations have published guidelines indicating that routine thrombophilia screening in patients presenting with thrombosis should not be performed. In this
case, results of the thrombophilia screen is not likely to justify an evidence-based modification of this patients management. Furthermore, the consulting provider indicated that the deep vein thrombosis was considered to be a provoked event. The medical evidence does not support thrombophilia screening in this setting. In sum, laboratory testing performed on 6/26/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


The patient is a 66-year-old male with history of bilateral greater saphenous vein (GSV) ablations. Despite the continued use of medical grade compression stockings for more than five months, he remains symptomatic with tired, heavy, achy legs and associated skin changes. He has no active skin ulcers. Ultrasound on 6/13/17 demonstrated prior bilateral GSV ablations, pathologic reflux in both short saphenous veins and refluxing tributaries, and pathologic reflux in both calf perforator veins. The patient has requested authorization and coverage for endovenous vein ablation. The Health Insurer has denied this request indicating that the requested services are considered investigational. The patient meets the criteria for the ablation of the short saphenous vein and the ultrasound guided sclerotherapy. The current medical literature indicates that the recommended size for ablation is 4.5 mm. This patients left small saphenous vein is 7.5 mm with pathologic reflux, and the right small saphenous vein is 4.2 mm with pathologic reflux. Ultrasound guided sclerotherapy is appropriate for the tributaries on the basis of size and reflux criteria, after the small saphenous veins are ablated. However, there is a lack of peer-reviewed literature supporting better outcomes with ablations of refluxing perforators compared to other therapies. These can be treated by ultrasound guided sclerotherapy, after the short saphenous vein ablations. Thus, the small saphenous vein ablations are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy while the perforator ablations are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, a portion of 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 partially overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

The parent of a 17-year-old male enrollee has requested reimbursement for wilderness therapy program provided from 7/11/16 through 9/21/16 and from 11/3/16 through 12/27/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees behavioral health condition. The physician reviewer found that there is some evidence in the medical literature that wilderness therapy is as effective as traditional psychotherapy. Prior to this patients initial admission to the wilderness therapy program on 7/11/16, the patient was noted to have worsening depressive and anxiety symptoms, difficulty with completing activities of daily living, and suicidal ideation.  He was socially withdrawn, refusing to attend school, and aggressive towards family members.  There are several published studies supporting the use of wilderness therapy in the adolescent population. Therefore, based on the support in the medical literature, the wilderness therapy program provided from 7/11/16 through 9/21/16 and from 11/3/16 through 12/27/16 was likely to have been of greater benefit than the available standard methods of treating this patients medical condition. 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: Overturned

Summary Reviewer 


The parent of a seven-year-old male enrollee has requested reimbursement and prospective authorization and coverage for applied behavioral analysis (ABA) therapy, in excess of 35 hours per week provided from 5/10/16 through 11/8/16. 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.  The physician reviewer found in this clinical setting, ABA therapy in excess of 35 hours per week provided from 5/10/16 through 11/8/16 was and is medically necessary for treatment of the patients medical condition. ABA therapy is medically indicated for children diagnosed with autism. The review by Reichow and colleagues shows that ABA started at a younger age provides improvements in cognitive skills, adaptive skills and language skills. In this case, the patient has received ABA therapy since his diagnosis in 2014. ABA therapy has been effective for him, however he continues to have self-injurious behaviors that include tapping/hitting, elopement and tantrum. Therefore, ABA therapy in excess of 35 hours per week were and are 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 2

The patient is a 61-year-old female who underwent testing with the DecisionDx melanoma gene testing to assess the metastatic risk of the 2.65 mm Breslow depth melanoma identified on her left ear. The patient has requested reimbursement for the DecisionDx melanoma assay provided on 6/30/14. The Health Insurer has denied this request indicating that the testing at issue was considered investigational. The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such at the DecisionDx Melanoma gene assay should not be used outside of clinical trials as its utility remains to be proven. Moreover, there is a paucity of data demonstrating that results of the DecisionDx assay results in treatment changes that improve health outcomes. Overall, the testing requested is not considered to be standard of care in the evaluation and treatment of melanoma. Accordingly, the DecisionDx melanoma assay provided on 6/30/14 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 54-year-old female enrollee has requested reimbursement for acute hospital stay from 12/30/17 through 2/11/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. At the time of admission, the records did not document that she required frequent treatment with intravenous analgesic medication. The documentation did not indicate an emergent need for surgical intervention. The current medical evidence does not support the services at issue in this clinical setting. Therefore, acute hospital stay provided from 12/30/17 through 2/11/18 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 54-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/06/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who has a history of breast cancer. The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  There is sufficient support for the service at issue in this clinical setting.  In this patients case, it was not unreasonable to perform surveillance mammography with the addition of tomosynthesis despite of the non-dense nature of her left breast, as there is an increased risk of developing a contralateral carcinoma.  Thus, digital breast tomosynthesis performed on 7/06/16 was likely to have been superior over 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 1

A 64-year-old male enrollee has requested authorization and coverage for cetuximab (Erbitux) to be given in conjunction with FOLFIRI. The Health Insurer has denied this request and reported that the requested medication regimen is investigational for the treatment of the enrollees medical condition. The physician reviewer found that Erbitux (cetuximab) is a monoclonal antibody targeting EGFR. It has been approved in several types of cancer, usually when given with chemotherapy or radiation therapy. The literature as to its use in esophageal cancer does not demonstrate convincing evidence of its efficacy. The randomized trial by Suntharalingam and colleagues did not demonstrate benefit to cetuximab when added to chemoradiation therapy in localized disease. Huang and colleagues noted that cetuximab failed to significantly improve the overall survival and progression-free survival for patients with localized or metastatic esophageal cancer. Overall, there is a lack of convincing data to indicate the usefulness of cetuximab in esophageal cancer. Therefore, cetuximab (Erbitux) to be given in conjunction with FOLFIRI is not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is a 55-year-old female who presented to the emergency room on 11/10/21 with a  
history  of  a  recent  sinus  infection  treated  with  antibiotics.  The  patient  has  requested 
reimbursement for a hospital stay from 11/10/21 through 11/12/21. The physician reviewer 
found that the submitted documentation supports the medical necessity for the services at issue. 
Acute inpatient care for a patient with suspected meningitis may be appropriate if the patient is 
immunocompromised,has altered mental status, hemodynamic instability, or other factors like 
those present in this case. In this case, patient may have had partially treated meningitis because 
of the antibiotic therapy she had received for sinusitis and, although unlikely because of the CT 
study, she may also have had a small parameningeal focus of infection related to her sinus 
infection. The acute changes in cells, protein, and glucose may imitate the findings in non-
bacterial meningitis in both of these situations. Barring use of polymerase chain reaction (PCR) 
testing or other rapid techniques to make a rapid etiologic diagnosis, the possibility of a partially 
treated  infection  needed  to  be  considered  pending  culture  results. In  this  clinical  setting, 
inpatient care while these issues were evaluated was medically indicated. Therefore, the hospital 
stay from 11/10/21 through 11/12/21 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 49-year-old male enrollee has requested reimbursement for Oncotype DX Colon Cancer Assay performed on 5/29/14. 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 use of 12-gene expression test (Oncotype DX Colon Cancer Assay) is unproven for predicting the likelihood of disease recurrence in patients with stage II colon cancer following surgery. There is a lack of prospective randomized solid phase II or III data to warrant its routine use.  Until prospective randomized data is published, the superior efficacy of the services at issue cannot be established.  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.