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

Summary Reviewer 2

A 46-year-old male enrollee has requested reimbursement for collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral corneal ectasia. The physician reviewer found that Corneal crosslinking is a U.S. Food and Drug Administration (FDA) approved procedure for corneal ectasia and post refractive ectasia.  The primary purpose of crosslinking is to halt the progression of corneal thinning that occurs with conditions such as keratoconus and post refractive corneal ectasia. The procedure involves soaking the corneal stroma with riboflavin and then using ultraviolet light to create chemical bonds between collagen fibrils within the stroma.  This stiffens the cornea and halts the thinning.  Prior to this treatment, patients with keratoconus who failed medical treatment (glasses, contact lenses) and whose disease continued to progress would go on to surgical management with corneal transplantation. There have been multiple studies published which demonstrate that patients who underwent corneal crosslinking showed an improvement in keratometry values, uncorrected visual acuity and best corrected visual acuity in contrast to sham group. Of note, this procedure is not considered a refractive or vision correcting as the primary purpose of crosslinking is to stabilize the cornea and prevent further thinning and bulging that is seen with keratoconus and post refractive ectasias. In addition, there have been studies that have shown an overall decrease in the number of penetrating keratoplasties performed since the introduction of crosslinking.  There is mounting evidence of the benefit of this treatment in patients diagnosed with keratoconus and post refractive ectasias who have progressive disease. Given the patients topographic evidence of post refractive ectasia, as well as the evidence of progressive disease, collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16 were likely to have been superior over any other methods for treatment of 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: Experimental
Decision: Upheld

Summary Reviewer 2

A 64-year-old female enrollee has requested reimbursement for gene testing performed on 10/30/17. 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 understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing prognostic information, the value of next generation sequencing to predict candidates for specific mutation-driven treatment holds promise but is not yet ready for routine clinical use. Although the ability to decipher genomic aberrations in individual breast cancers to the single nucleotide resolution is now possible, there is a lack of data to show that this information can guide treatment decisions for patients with metastatic breast cancer. The use of next generation sequencing, such as with FoundationOne testing, continues to be the subject of ongoing clinical trials. In sum, gene testing performed on 10/30/17 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 33-year-old female who presented to her provider on 1/22/18. The records noted a body mass index of 41.1 kg/m2, consistent with obesity, and comorbidities including snoring/possible sleep apnea, and musculoskeletal pain. The physician reviewer found that the submitted records fail to demonstrate the medical necessity of the requested services. No gastrointestinal symptoms are reported. The most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines for appropriate use of endoscopy recommend endoscopy for investigation of upper gastrointestinal symptoms when those symptoms are refractory to proton pump inhibitor taken properly for four to eight weeks without response, or for specific indications such as dysphagia. In this case, the provided information does not clearly document any such symptoms, or if symptoms were present, an attempt at treatment. The provider has not reported how management will change (i.e. surgery would be cancelled) based on findings. Endoscopy in asymptomatic patients before bariatric surgery has not been established as standard. Large studies have supported pre-surgery endoscopy only in symptomatic patients. For these reasons, esophagogastroduodenoscopy is not supported as medically necessary for the evaluation of this patients pre-bariatric surgery status in this case. Therefore, flexible esophagogastroduodenoscopy with biopsy performed on 3/03/18 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 35-year-old female enrollee has requested reimbursement for inpatient behavioral health services provided on 4/30/19 through 5/02/19. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that in cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System is indispensable in determining necessary level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no current suicidal or homicidal ideation, plan, intention or severe distress. With regards to functional status, the records support a score of 1 due to no problems with group attendance. Per the records, the patient found the groups to be supportive. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2. In terms of level of stress of the recovery environment, the records support a score of 1 due to a low stress environment. With regards to level of support for the recovery environment, the records support a score of 1 due to family support and availability of treatment resources. With regards to treatment and recovery history, the records support a score of 2 given her previous treatment. The records noted prior psychiatric hospitalizations, and the patient reportedly had been minimally engaged with outpatient psychiatry following discharge from her prior hospitalization. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into her need for treatment along with insight into her treatment needs. Thus, the patient has a composite score of 10. This correlates with treatment in a community-based outpatient clinic setting. Therefore, inpatient behavioral health services provided on 4/30/19 through 5/02/19 were not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 65-year-old female enrollee has requested reimbursement for autonomic nerve function testing performed on 3/26/15.  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 the superior efficacy of the services at issue has not been established.  The patients history is not well-documented and does not indicate features of neuropathy.  The examination was inadequate to discern if neuropathy was a realistic consideration. Electrodiagnostic test results were not submitted for review.  If small fiber neuropathy is within the differential, commonly such individuals would be assessed by a neurologist familiar with neuropathy, and undergo more detailed neurologic clinical examination.  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 3


A 55-year-old female enrollee has requested reimbursement for CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy provided from 2/10/15 through 2/13/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found in this case, the patient has a history of mast cell disorder, multiple chemical sensitivities and food allergy.  Allergen immunotherapy is a well-standardized treatment options.  The current national guidelines indicate that allergen immunotherapy may be efficacious in the treatment of allergic rhinitis, allergic conjunctivitis, allergic asthma, and stinging insect hypersensitivity.  In this case, there is no evidence of the above diagnoses.  As such, CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy provided from 2/10/15 through 2/13/15 was not likely to have been more efficacious than other treatment options.  Based upon the information set forth above, the services at issue were 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 2

The patient is a 56-year-old male who presented on 7/31/16 with ventricular fibrillation due to an acute anterior myocardial infarction, requiring defibrillation prior to hospital arrival.  He was found to have an occluded left anterior descending coronary artery on urgent catheterization and was treated with coronary stent placement.  Within the next 24 hours, he had recurrent cardiac arrests due to polymorphic ventricular tachycardia thought to be related to ischemia.  Repeat cardiac catheterization was performed, and balloon angioplasty to the left anterior descending preexisting stent and additional stent placement to a severe distal right coronary stenosis both were performed.  There was no recurrent sustained ventricular tachycardia, ventricular fibrillation or cardiac arrest after repeat coronary intervention on 8/01/16.  He was discharged on 8/05/16.  The patient has requested reimbursement for wearable cardioverter defibrillator. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of this patient. This patient presented with a cardiac arrest in the setting of acute myocardial infarction and then had recurrent ventricular tachycardia/cardiac arrest within the first 24 hours of infarction in the setting of recurrent ischemia. In this circumstance, ventricular tachycardia/fibrillation within the first 24 hours of acute myocardial infarction is generally not predictive of subsequent ventricular tachycardia/ventricular fibrillation.  In addition, the patients ejection fraction was not reduced to 35% or less. The documentation does not support the medical need for immediate placement of a defibrillator (wearable or implantable).  Placement of a prophylactic defibrillator is not recommended until a period of time greater than 90 days where continued left ventricular dysfunction (ejection fraction 35% or less) is documented to persist despite appropriate treatment. A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explantation. Thus, the wearable cardioverter defibrillator was not likely to have been more effective than other treatment options. Based upon the information set forth above, the device at issue was 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 3

The parent of a 15-year-old male enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 5/13/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that the patient is a 15-year-old male with Crohns disease and perianal fistulas.  On 3/02/16, he presented with epigastric pain, but no diarrhea or blood in the stool after two doses of Remicade.  Prometheus Anser IFX testing was ordered to be performed prior to the next infusion.  Per the 9/09/16 provider note, Remicade dose was increased based on the test results.  The Health Insurer has denied reimbursement for Prometheus Anser IFX testing performed on 5/13/16.  Per the Health Insurer, the services at issue were investigational for the evaluation of this patient. In this case, Anser IFX was ordered to determine Remicade level and whether antibodies to infliximab were present.  The use of Anser IFX to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease.  The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have clear Remicade levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing.  Based on clinical literature, Prometheus Anser IFX testing performed on 5/13/16 was not likely to have been more efficacious 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: Experimental
Decision: Upheld

Summary Reviewer 2 
 
A 63-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene test 
(CPT 81529) performed on 5/27/21. 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 Melanoma is a cancer that is curable in its earliest stages. 
Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph 
nodes for those with a high depth of invasion, from 0.76 mm to 1.0 mm. Metastases to regional 
lymph nodes may be amenable to excision but suggest a high risk for the development of 
metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. 
While Gerami and colleagues report that GEP signature accurately predicted metastasis risk in a 
multicenter cohort of primary cutaneous melanoma tumors, the patients analyzed were part of 
a high-risk cohort, and there appears to be some lack of consistency between various genes being 
used as biomarkers. The use of data from DecisionDx-Melanoma is not part of routine analysis 
following SLNB. The service at issue is novel, and it unclear how its results would be incorporated 
it into the treatment algorithm beyond standard staging techniques recommended by the 
National Comprehensive Cancer Network (NCCN). Therefore, the DecisionDx-Melanoma gene 
test  (CPT  81529)  performed  on  5/27/21  was  not  likely  to  have  been  more  beneficial  for 
evaluation of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 29-year-old female enrollee has requested reimbursement for the human papilloma virus (HPV) testing provided on 8/26/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for HPV. The physician reviewer found that overall, the routine inclusion of HPV screening in women under age 30 does not provide additional benefit over cytology and increases the risk of unnecessary interventions. This patient was under age 30. The guidelines from the American Cancer Society (ACS) and the American Society for Colposcopy and Cervical Pathology (ASCCP), and American Society for Clinical Pathology (ASCP) all recommend delaying co-testing until after age 30. Thus, there is a lack of documentation supporting an indication for the HPV testing performed on 8/26/16, and the testing 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 


The parent of an eight-year-old male enrollee has requested authorization and coverage for applied behavioral analysis (ABA) therapy. The Health Insurer has denied this request indicating that the requested therapy is not medically for treatment of the enrollees behavioral health conditions.  The physician reviewer found that in this clinical setting, ABA therapy is not medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, a diagnosis of autism has not been established. In addition, there is a lack of peer-reviewed literature supporting ABA therapy for the treatment of generalized anxiety disorder, developmental coordination disorder or adjustment reaction. There is also a lack of research supporting ABA for treatment of behavioral regulation or self-control outside of a diagnosis of autism spectrum disorder. The standard of care for treating generalized anxiety disorder include medications and counseling (Dobson and Strawn; Mohatt, et al).  Moreover, the patient has not been evaluated for autism by a developmental and behavioral pediatrician utilizing Autism Diagnostic Observation Schedule (ADOS) and Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnostic criteria. Therefore, ABA therapy has not been established as medically necessary for treatment of the patients medical condition. Therefore, the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 54-year-old female enrollee has requested reimbursement for color-flow Doppler echocardiography performed on 3/29/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees chest pain and dyspnea. The physician reviewer found that this patient had risk factors for coronary heart disease and symptoms of both chest pain and dyspnea. She was referred for color-flow Doppler echocardiography. Given her symptoms of chest pain and dyspnea, along with the fact that this was the first and only investigation of these complaints, assessment of her cardiac valves and pulmonary pressures was reasonable, indicated and appropriate in order to rule out both ischemic and valvular heart disease as an etiology of her chest pain and dyspnea symptoms. Therefore, color-flow Doppler echocardiography performed on 3/29/18 was likely to have been more efficacious than other methods of 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 1

A 61-year-old male enrollee has requested authorization and coverage for intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery (including anterior cervical procedures). The Health Insurer indicates that the requested services are investigational for the treatment of the enrolleeas medical condition. Therefore, the Health Insurer has denied coverage for the requested services. At issue is whether the requested services are likely to be more beneficial for treatment of the enrollee's condition than any available standard therapy. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This is a spinal deformity operation plus placement of pedicle screws. Intraoperative monitoring is needed to monitor the L5 nerve root during reduction and correction of spondylolisthesis to minimize foot drop and permanent palsy. Additionally, the requested services will allow the provider to monitor for any breach of pedicle screws. Given how long the surgery will take in prone position, the requested services can also allow the provider to monitor the upper extremity to make sure the patient does not end up with a brachial plexus and/or ulnar nerve palsy. Therefore, intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery (including anterior cervical procedures) is likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 55-year-old female enrollee has requested authorization and coverage for tremfya 100 mg/mL syringe. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The American College of Rheumatology/National Psoriasis Foundation published updated guidelines in 2019. Severe psoriasis is defined as disease affecting greater than 5 to 10% body surface area or disease affecting the face, palms or soles of feet. The National Psoriasis Foundation considers Tremfya a first-line therapy when ultraviolet B therapy is not available. The American Academy of Dermatology and the National Psoriasis Foundation issued a joint position statement in April 2019. Currently, there are 11 biologic agents on the market or in clinical trials for the treatment of psoriasis. Tremfya was approved by the U.S. Food and Food Drug Administration in July 2017 for use in psoriasis. Tremfya is recommended as a monotherapy treatment option in adult patients with scalp, nail, and plaque-type palmoplantar psoriasis. In this case, the patient has severe psoriasis with involvement of the scalp, foot and hands over 15% body surface area. The patient has tried and failed topical steroids, oral steroids, cyclosporine A, and Taltz (not tolerated). Given the scenario of failure of standard therapies for severe psoriasis, it is reasonable to consider a trial of biologics. The requested medication is medically appropriate in this clinical setting. Therefore, Tremfya 100 mg/mL syringe is medically necessary for the treatment of this patient.