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

Summary Reviewer 1


A 57-year-old female enrollee has requested reimbursement for tumor necrosis factor antagonist testing performed on 4/04/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found it is not standard of care to measure tumor necrosis factor drug levels and their antibodies in patients failing on a biologic. The Anser tests for both infliximab and adalimumab have been available for several years, and their role in clinical management continues to be defined.  There is a lack of evidence from prospective controlled trials demonstrating superiority over standard clinical management.  Patients with inflammatory bowel disease experience disease refractory symptoms for a number of reasons unrelated to tumor necrosis levels.  All told, tumor necrosis factor antagonist testing performed on 4/04/15 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: Experimental
Decision: Upheld

Summary Reviewer 1


A 61-year-old male enrollee has requested reimbursement for physical therapy services performed from 8/27/15 through 12/5/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of low back pain, knee pain and bilateral arm numbness. The physician reviewer found that the medical evidence has not demonstrated the superior efficacy of the services at issue in this clinical setting.  Huang and colleagues noted that cupping therapy is promising for pain control and may improve the quality of life but the research shows that that cupping in the treatment of low back pain requires further research. In a meta-analysis by Yuan and colleagues, they were unable to draw definitive conclusions as to the superior efficacy of gua sha, and other forms of Chinese manipulations in treating disability associated with chronic neck pain or chronic back pain. In addition, their study could not substantiate the efficacy of tui na and moxibustion over other forms of therapy. Moreover, there was a lack of sustained, significant, objective, functional improvement or quantifiable response to the physical therapy services in this patients case. In sum, the physical therapy services provided between 8/27/15 and 12/5/15 were not likely to have been superior to other forms of therapy for the treatment of this patients medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been 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: Upheld

Summary Reviewer 1

A 30-year-old female enrollee has requested reimbursement for gene expression profiling performed on 6/29/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found there is a lack of medical literature supporting the testing at issue in this clinical setting. According to the results of analysis of patients Decision Dx Melanoma testing, the tumor was classified as Class 1A with a low risk of near-term within five years, such as 96% metastasis free rate. According to the standard analysis of such risk, the lesions of 1-2 mm depth have a risk of 80-96% of recurrence. Therefore, the gene expression profiling performed on 6/29/16 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: Medical Necessity
Decision: Overturned

Summary Reviewer 
The patient is a 19-year-old male who has been diagnosed with Crohnas disease. The patient has requested authorization and coverage for Stelara injections 90 mg/ml. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the current medical literature supports the use of Stelara in this case. Stelara has been approved by the U.S. Food and Drug Administration (FDA) for Crohnas disease. Sandborn and colleagues performed a large randomized controlled trial that demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-to-severe Crohnas disease that was resistant to anti-tumor necrosis factor (TNF) therapy. The study by Kopylov and colleagues showed a 73.7% response in patients with anti-TNF-resistant Crohnas disease, and 80% of responders maintained remission for six months. A significant majority of these patients were able to discontinue steroids. The mechanism of Stelara (ustekinumab) is entirely different than that of immunosuppressants and anti-TNF medications, which the patient has failed. A recent study by Wils and colleagues demonstrated that a significant majority of patients who have failed an anti-TNF medication achieve and maintain response with Stelara. American Gastroenterological Association guidelines for the treatment of Crohnas disease recommend ustekinumab in patients with failure of an anti-TNF medication such as Remicade. In this case, Stelara can control disease and prevent further complications (such as need for surgery) in this patient with severe disease, currently uncontrolled disease, and prior complications such as fistula. Guidelines do not recommend Humira before the use of Stelara, or Humira as safer or more effective than Stelara for the treatment of Crohnas disease. Therefore, Stelara injections 90 mg/ml are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 60-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that there are studies comparing photons and protons in radiation therapy. The emerging technology committee of the American Society for Radiation Oncology (ASTRO) published an evidence-based review of proton beam therapy, which concluded that, although proton therapy holds promise, there is insufficient evidence that it is superior or even comparable to photon radiotherapy. Although proton therapy is an option for prostate cancer, there is a lack of data demonstrating substantial benefits over intensity modulated radiation therapy (IMRT). For these reasons, the requested proton beam radiation therapy is not likely to be more beneficial for treatment of the patients medical condition than any available modality. Based upon the information set forth above, I have determined the requested services 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: Upheld

Summary Reviewer 1

A 63-year-old male enrollee has requested reimbursement for Decision Dx Assay testing performed on 7/18/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees melanoma. The physician reviewer found there is insufficient support in the peer-reviewed literature for the testing at issue in this clinical setting. According to the results of analysis of the patients melanoma performed with Decision Dx Melanoma, the tumor was classified as Class 1A with a low risk of near-term within five years metastatic disease, such as 96% metastasis free rate. According to the standard analysis of such risk, the lesions of 1-2 mm depth have a risk of 80-96%. Although the Decision Dx Melanoma signature may be an independent predictor of metastasis risk, there are a lack of peer-reviewed published studies confirming this hypothesis. All told, the Decision Dx Assay testing performed on 7/18/16 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 3

A 63-year-old female enrollee has requested reimbursement for laboratory testing (collagen crosslink testing) performed on 2/25/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of osteoporosis.  The physician reviewer found that the current medical evidence has not established the superior efficacy of the services at issue. The value of monitoring therapy with the use of biochemical markers of bone turnover to aid in clinical decision is controversial. This testing can be variable and subject to timing and dietary intake. Additionally, there is a lack of assay standardization. Thus, laboratory testing (collagen crosslink testing) performed on 2/25/17 was not likely to have been of greater benefit than 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: Upheld

Summary Reviewer 


A 40-year-old male enrollee has requested reimbursement for emergency room services provided on 1/24/17. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found the patient is a 40-year-old male who presented to the emergency department on 1/24/17 with reports of back pain. He reported low back pain that had commenced two weeks prior. Carrying his daughter on his shoulders had worsened his discomfort. Ibuprofen, rest, and ice had not alleviated his pain. He denied any fever, numbness, tingling, or loss of bowel or bladder control. The patients vital signs included blood pressure of 131/92, respiratory rate of 18, and a temperature of 98.8 F. Mild discomfort in the lumbosacral region was noted without radiation or step-offs. He had a positive straight leg raising and antalgic gait. No obvious sensory or motor deficits were present. The record notes that the patient had good strength of his hip, knee, and ankle dorsi- and plantar flexion. Normal reflexes were present. An x-ray revealed mild degenerative changes with endplate spur formation at L3-4 and mild facet arthropathy at L4-5 and L5-S1. He was treated with intramuscular Toradol and Flexeril. The patient was assessed with back pain and discharged home with improved symptoms. The patient has requested reimbursement for emergency services provided on 1/24/17. At issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with back pain that had commenced two weeks prior. He had not suffered any trauma. He denied any neurologic symptoms. The patient was afebrile with normal vital signs. He had normal motor strength and no sensory deficits. Given that the patients symptoms were not acute in onset or severe, and he had not suffered any trauma, his symptoms do not meet prudent layperson criteria for an emergency medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services provided on 1/24/17 did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
The patient is a 51-year-old female. An operative report dated 4/28/22 reported that the patient 
underwent transanal excision of circumferential rectal mass with recto-anal anastomosis for treatment 
of a circumferential tubulovillous adenoma. The physician reviewer found that the issue is whether 
inpatient admission from 4/28/22 to 4/29/22 was medically necessary for the treatment of this patient. 
The submitted documentation does not support the medical necessity of the services at issue. In this 
case, the records showed that the patient was relatively young, at 51 years of age, without severe 
comorbidities or complications after surgery. Given that, the additional care, such as pain control and 
Foley catheter placement, could have been provided at a lower level of care such as in observation. 
Accordingly, the services at issue were not medically necessary for the treatment of this patient. 
Therefore, inpatient admission from 4/28/22 to 4/29/22 was not medically necessary for the treatment 
of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 35-year-old female has requested reimbursement for Oncotype Dx Colon Cancer Assay provided on 11/16/18. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that many experts consider chemotherapy versus avoiding the toxicities of chemotherapy in such a young patient. There is a lack of consensus from expert groups as to which, if any, patients with stage II disease should receive adjuvant chemotherapy. In the study by Venook and colleagues, the recurrence score (RS) appeared to be most discerning for patients with T3 tumors that were proficient for MMR enzymes, in whom the pre-specified low-RS and high-RS groups had average five-year recurrence risks of 13 and 21 percent, respectively. Forty-four percent of patients with T3N0 pMMR tumors fell into the low-RS category and, thus, may have been spared from receiving chemotherapy. There is some support for the services at issue in this patients case. In sum, Oncotype DX Colon Cancer Assay performed on 11/16/18 was likely to have been more effective than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 65-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 6/13/17. 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 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. Another advantage of tomosynthesis is better delineation and characterization of breast masses. In very recent years, there have been several studies that have supported the use of breast tomosynthesis as a more accurate study than routine screening mammography. Skaane and colleagues noted the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Friedewald and colleagues noted that the addition of tomosynthesis to digital mammography was associated with a decrease in recall rate and an increase in cancer detection rate. In this patients case, given her recent history of breast cancer, performing her surveillance with breast tomosynthesis was appropriate. Thus, breast tomosynthesis performed on 6/13/17 was likely to have been superior over other available modalities for 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 59-year-old female enrollee has requested has requested reimbursement for physical therapy treatment provided from 12/1/14 through 12/30/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees hip pain, wrist pain, spinal stenosis and shoulder pain. The physician reviewer found that physical therapy is a widely used treatment for lumbar spine pathology and patellofemoral pain. The duration and frequency of treatment are not adequately addressed in the medical literature. Delitto and colleagues indicate that there is benefit to therapeutic exercise tailored to the patients condition. In this case, the patient received documented therapeutic benefit through the first 13 sessions of physical therapy. However, the documentation submitted for review does not show a need for continued skilled services as of 12/1/14. The patient underwent physical therapy for an extended period of time without adequate support for the medical necessity of these interventions. She had more than 20 physical therapy sessions for her lumbar stenosis and patellofemoral pain by 12/1/14. Additional skilled treatment for these conditions was not medically necessary. In addition, the patient had wrist and shoulder pain in 2015 but the physical therapy notes do not show these issues being systematically evaluated and treated. The physical therapy sessions provided for her wrist and shoulder pain were not medically necessary. As such, physical therapy treatment provided from 12/1/14 through 12/30/15 has not been established as medically necessary for treatment of the patients medical condition. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 56-year-old male enrollee has requested authorization and coverage for proton treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees tumor of the hypopharynx. The physician reviewer found that in this clinical setting, there is a lack of published literature that compares clinical outcomes of proton beam radiotherapy to standard photon techniques. Consensus group guidelines do not support the use of proton therapy in this setting. Currently, proton therapy for head and neck cancer is being evaluated in National Cancer Institute sponsored trials. However, there is currently insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit beyond conventional radiation therapy. As such, proton therapy is not likely to be superior to the standard options available for treatment of this patients medical condition. Therefore, based upon the information set forth above, the requested services 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 66-year-old female enrollee has requested authorization and coverage for Lantus. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees diabetes. The physician reviewer found that there is sufficient support in the medical literature for the requested medication in this clinical setting. The patient was placed on Levemir and Basaglar to control her diabetes. She had side effects and failure to respond properly to Levemir and Basaglar. The alternative Levemir insulin and the biosimilar insulin Basaglar did not provide her with similar benefit to Lantus and were associated to poor control. It is important to note that Lantus is not interchangeable with Levemir. Levemir is a different insulin analog and has a different pharmacokinetic profile. Usually, patients on Levemir require twice a day dose and larger doses, to mimic the effect of Lantus (Wallace, et al). The patient tried Levemir and Basaglar with poor response.  In this patients case, the alternative insulins were not effective in managing her diabetes. The patient was well controlled on Lantus. Accordingly, treatment with Lantus has been demonstrated as medically necessary. 

Therefore, as stated above, 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

A 27-year-old male enrollee has requested reimbursement for the pneumatic compressor or deep vein thrombosis (DVT) system provided from 4/5/16 through 5/4/16. The Health Insurer has denied this request indicating that the equipment at issue was considered investigational for treatment of the enrollees left knee with patellar tendon rupture, anterior cruciate ligament (ACL) rupture, medial cruciate ligament (MCL) injury and medial meniscus injury. The physician reviewer found that the use of intermittent pneumatic compression in this case was supported by the high risk for DVT as a result of the prolonged disability, obesity, and history of smoking. In addition, dynamic intermittent compression combined with cryotherapy decreases analgesic drug requirements after ACL reconstruction and improves the postoperative recovery of range of knee motion. Murgier and Cassard reported that the use of intermittent pneumatic compression combined with cryotherapy after ACL reconstruction resulted in decreased pain, inflammation, and need for narcotics after surgery in addition to the mechanical DVT prophylaxis. Waterman and colleagues found that the efficacy of combined cryotherapy and dynamic compression compared to cryotherapy alone demonstrates the advantage of using this combination after ACL reconstruction. In light of the foregoing, the use of intermittent pneumatic compression or DVT system provided from 4/5/16 through 5/4/16 was reasonable, appropriate, and better than any other available standard treatment. Based upon the information set forth above, the equipment at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.