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

Summary Reviewer 3


A 29-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 2/25/16.  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 in this patients case, Anser IFX testing was ordered to determine Remicade (infliximab) 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 infliximab 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 the clinical literature, Anser IFX testing performed on 2/25/16 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: Overturned

Summary Reviewer 2

The parent of a 12-year-old male enrollee has requested authorization and coverage for real-time intra-fraction target tracking for planned proton beam radiotherapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees craniopharyngioma status post resection.  The physician reviewer found that Overall penumbra volume should be reduced by 50-70% as a result of tracking and therefore may provide reduction in hypothalamic and brain doses. In light of the patients cerebrovascular accident, any further damage to normal central nervous system tissues is likely to be detrimental. The 2 mm or better fixation offered by a thermoplastic mask is adequate to support that the real-time intra-fractional target tracking is likely to be more beneficial than standard alternatives since the tumor is already in contact with the optic pathway. Based upon the information set forth above, I have determined 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 overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 53-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma test performed on 11/06/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas 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 high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on the DecisionDx-Melanoma test for melanoma has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma test performed on 11/06/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 50-year-old female has requested authorization and coverage for sacroiliac joint fusion.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is sufficient support for the requested services in this clinical setting.  Polly and colleagues performed a randomized controlled trial comparing minimally invasive sacroiliac joint fusion using triangular titanium implants to nonsurgical treatment at 12 months.  A total of 148 patients with sacroiliac joint dysfunction were randomly assigned to minimally invasive sacroiliac joint fusion with triangular titanium implants or nonsurgical treatment.  The conclusion was that this level one study showed that minimally invasive sacroiliac joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with sacroiliac joint dysfunction caused by degenerative sacroiliitis or sacroiliac joint disruptions.  Pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment.  Based upon a review of the literature, the requested sacroiliac joint fusion is likely to be more effective than other treatment options.  Based upon the information set forth above, 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 overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 23-year-old female enrollee has requested reimbursement for the substance use residential rehabilitation services provided from 10/10/16 through 1/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees substance abuse. The physician reviewer found that the records provided for review document that this patient showed mild post-acute withdrawal symptoms and there was no evidence of suicidal or homicidal ideation. She attended to her activities of daily living and was cognitively intact. Emotionally she related that she wanted to grieve before participating in treatment. She did not demonstrate impulsivity. She did not show motivation or cooperation. Medically she was stable as her rheumatoid arthritis and medication therapy could have been managed on an ambulatory basis. She was at risk for relapse, however she was highly resistant. It was not until 10/15/16 that she began to show cooperation and motivation. Overall, the patient did not require 24-hour per day supervised medical and nursing level of care in residential treatment. She could have been treated in a less restrictive treatment setting in conjunction with community supports with 12 step programs, and a Subutex maintenance program on an outpatient basis. Thus, the substance use residential rehabilitation services provided from 10/10/16 through 1/6/17 was not medically necessary for treatment of this patients medical condition. Based on these findings, 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 2

A 26-year-old female enrollee has requested reimbursement for CPT code 81291 performed on 10/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a family history of a clotting disorder. The physician reviewer found there is is support for the services at issue in this clinical setting. As it relates specifically to evaluation of pregnancy losses, the testing performed is not indicated. However, the medical evidence supports testing when a patient or a first-degree relative has a history of a thrombotic event. This patients family history indicates that she may be at higher risk during pregnancy and during the immediate postpartum time period, and the results of this testing may impact patient management. Therefore, CPT code 81291 performed on 10/11/17 was 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 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 59-year-old male enrollee has requested reimbursement for Guardant 360 testing performed 
on 3/31/21. 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 cell-free/circulating tumor DNA testing should not be used in lieu of a 
histologic tissue diagnosis. Some laboratories offer testing for molecular alterations examining 
nucleic acids in peripheral circulation, most commonly in processed plasma (sometimes referred 
to as liquid biopsy). Studies have demonstrated cell-free tumor DNA testing to generally have 
very high specificity, but significantly compromised sensitivity, with up to 30% false-negative 
rate. Standards for analytical performance characteristics of cell-free tumor DNA have not been 
established,  and  in  contrast  to  tissue-based  testing,  no  guidelines  exist  regarding  the 
recommended performance characteristics of this type of testing. Cell-free tumor DNA testing 
can  identify  alterations  that  are  unrelated  to  a  lesion  of  interest,  for  example,  clonal 
hematopoiesis of indeterminate potential. This patient did not have enough tissue for molecular 
testing for driver mutations, and liquid biopsy was performed. The medical evidence supports 
the services at issue in this setting. Therefore, Guardant 360 testing performed on 3/31/21 was 
likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

The patient is a 55-year-old female with a history of rheumatoid arthritis manifested by synovitis of the small and large joints and fatigue. On 8/18/16, the records noted that she had been treated with Remicade, methotrexate and Xeljanz. The documentation indicated that the patient had responded to Remicade in the past, but this was discontinued due to cost.  The provider reported reluctance to resume Remicade due to concern for infusion reaction. The provider ordered Prometheus Anser IFX testing.  The Health Insurer has denied reimbursement for Prometheus Anser IFX testing performed on 8/19/16.  Per the Health Insurer, the services at issue were investigational for the evaluation of this patient.  The current medical evidence does not support the services at issue in this patients case.  Prometheus Anser IFX testing can measure antibodies to Remicade (infliximab). However, there is a lack of peer-reviewed, evidence-based medical literature to support the use of Prometheus Anser IFX testing in the management of rheumatoid arthritis. Additionally, the available medical records do not adequately document the providers rationale for the request of this test.  All told, the superior effectiveness of Prometheus Anser IFX testing performed on 8/19/16 has not been 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.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 51-year-old male enrollee has requested reimbursement for home healthcare services which include intravenous infusion of ceftriaxone, Benadryl, associated supplies and office visits with Miguel Gonzalez, MD from dates of service 9/11/15 through 12/09/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient has a long history of a variety of non-specific complaints.  The clinical evidence and the laboratory studies provided for review do not support a diagnosis of any tick borne diseases or Lyme disease.  The Borrelia burgdorferi serologies completed in March 2015 are negative.  In spite of this, the provider ordered intravenous ceftriaxone.  This drug is recommended for Lyme disease associated arthritis, carditis or neurological disease.  The records do not document that this patient had the rash typical of early Lyme disease, and his reported symptoms are not suggestive of this diagnosis.  In sum, home healthcare services which include intravenous infusion of ceftriaxone, Benadryl, associated supplies and office visits with Miguel Gonzalez, MD from dates of service 9/11/15 through 12/09/15 were not medically indicated for the treatment of this patient.  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 1

A 62-year-old male enrollee has requested reimbursement for blood test (protein biomarker tests or 4Kscore) provided on 10/29/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for developing metastases. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The records document a prostate-specific antigen (PSA) level of 0.96 ng/mL and a palpable nodule. The patient had a negative biopsy for prostate cancer. Per the medical evidence, 4Kscore is indicated for patients with PSA levels greater than 3 ng/mL without a palpable lesion. The medical evidence does not support the services at issue in this patients case, as the records noted a palpable lesion and a PSA level which was below 3 ng/mL. Therefore, the blood test (protein biomarker tests or 4Kscore) performed on 10/29/18 was not likely to have been more efficacious than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 14-year-old male enrollee has requested reimbursement for residential mental health treatment services provided from 4/25/16 through 12/31/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). The physician reviewer found that the records provided for review do not support the medical necessity of residential mental health treatment services provided from 4/25/16 through 12/31/16 for management of this patients medical condition. There was no evidence that the patient had severe and persistent psychiatric symptoms that results in impairment in multiple settings that require active treatment in a 24-hour supervised setting. Further, there was no evidence of suicidal or homicidal ideations, no evidence of psychosis, and no evidence of physical aggression during this period of time. The documentation suggests the patient could have reasonably been treated at a less intrusive, less invasive level of care such as outpatient treatment. Given these findings, the residential mental health treatment services provided from 4/25/16 through 12/31/16 were not medically necessary. Based on the foregoing discussion, 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: Overturned

Summary Reviewer 2

A 63-year-old female enrollee has requested reimbursement for unlisted laboratory services provided on 7/02/19 and 1/28/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that ClonoSEQ is a type of next-generation sequencing used to evaluate for minimal residual disease (MRD). It has been approved by the U.S. Food and Drug Administration (FDA) for MRD assessment in myeloma. A baseline sample is required to identify the dominant clonotype, but the study can be performed on both fresh and stored samples. It is not impacted by therapeutic monoclonal antibodies. The National Comprehensive Cancer Network (NCCN) guidelines recommend consideration of using MRD for monitoring patients. The patient has had two tests, the first in 2019 to establish a baseline and the most recent to evaluate response to current therapy. There is sufficient support for the services at issue in this setting. Therefore, unlisted laboratory services provided on 7/02/19 and 1/28/20 were likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

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 who reported palpitations. He was evaluated with a 30-day event monitor which demonstrated an episode of atrial fibrillation lasting 30 seconds. The patients provider recommended an implantable loop recorder to assist with treatment planning given the risks of bleeding if anticoagulation was initiated. 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. There is a lack of support for the device at issue in this patients case. The medical evidence does not support an implantable loop recorder for monitoring for atrial fibrillation burden in this clinical setting. The use of an implantable loop recorder is supported if the patient has had cryptogenic stroke or recurrent syncope and has had negative results of external electrocardiogram monitoring. This patient was shown to have a 30-second episode of atrial fibrillation on the initial event monitor performed. In sum, the implantable ambulatory event monitor provided on 12/28/17 was not likely to have been superior over other available 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 46-year-old female enrollee has requested authorization and coverage for breast reconstruction surgery.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee, who is status post breast implant placement. The physician reviewer found the patient is status post bilateral augmentation mammaplasty for apparent aesthetic reasons.  Following traumatic injury, she had significant shoulder pain and weakness related to a neuropathy.  She has undergone reconstructive procedures in order to improve the function of her shoulder, as well as physical therapy.  Multiple providers have recommended implant removal or breast reduction to allow for improved function.  However, the plastic surgery recommendation is for reducing the implant size by 50 cc, performing a mastopexy, and placing a Xenograft.  These procedures are not medically necessary.  However, as the implant size of 350 cc may be contributing to her chronic pain and functional impairment, implant removal may provide improved relief given failure of other treatment.  Therefore, as the patients functional impairment from a previous traumatic injury may improve with implant removal, removal of implants is medically indicated.  No other surgical intervention would likely provide reasonable improvement.  Therefore, a portion of the requested services is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 20-year-old male enrollee has requested reimbursement for the human T-lymphotropic virus (HTLV) testing performed on 4/25/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees sperm prior to banking. The physician reviewer found that currently, the U.S. Food and Drug Administration (FDA) requires all sperm donors, anonymous and directed, to be tested for human immunodeficiency virus (HIV), hepatitis B and hepatitis C, syphilis, human T-lymphotropic virus types I and II, cytomegalovirus, chlamydia trachomatis, and neisseria gonorrhea. Future infectious profile for the patient may differ from current profile at the time of the sperm donation. Hence the need to define the microbial profile of the patient at the time of the donation. Given that this patient has Ewing sarcoma and is undergoing chemotherapy, semen preservation is indicated. Thus, the HTLV testing performed on 4/25/16 was appropriate and likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 43-year-old male enrollee has requested reimbursement for Anser IFX testing performed on 8/09/15.  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 there is sufficient support for the services at issue in this clinical setting.  This patient has had interrupted therapy with Remicade.  He was failing all therapy and may require extensive surgery. Remicade was restarted, but he appeared to be having an immune response to therapy.  It was important to determine if there were antibodies as their presence will make further therapy futile.  In sum, Anser IFX testing performed on 8/09/15 was likely to have been superior over 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.