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

Summary Reviewer 3

The patient is a 61-year-old female who was diagnosed with advanced stage serous ovarian cancer at surgery in 2008. The surgery was followed by six cycles of cisplatin and Taxol. She had recurrence and was treated with a variety of chemotherapeutic agents, including carboplatin, Avastin, Gemzar, Doxil, and Topotecan. She also had been treated on a clinical trial with olaparib. The patient has requested reimbursement for blood testing performed on 3/16/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational. FoundationOne is a molecular assay that explores the mutations of an individual patients cancer cells. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the FoundationOne assay adds to decision making ability, or yields a result that is reliably clinically beneficial. There are non-randomized studies exploring the value of molecular profiling, but the results have not been convincing as to the efficacy of such an approach to treatment (Von Hoff, et al). A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment (LeTourneau, et al). Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. All told, the blood testing performed on 3/16/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2
A 27-year-old female enrollee has requested authorization and coverage for proton beam therapy for six weeks. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees breast cancer. The physician reviewer found that there is a lack of clinical data in the medical literature to suggest that treatment with proton beam radiation offers a superior clinical benefit when compared to conventional radiation therapy techniques for breast cancer. The standard techniques to use in this clinical setting are with three-dimensional conformal or intensity modulated radiation therapy with photons instead of protons. Consensus group guidelines do not support the use of proton therapy in this setting (National Comprehensive Cancer Network Guidelines). Also, there is a lack of level I evidence to support the use of proton therapy for the treatment of breast cancer. There is a lack of clinical data to suggest that treatment with proton techniques will be able to improve the sparing of the skin, heart, and/or lungs compared to standard intensity modulated breast radiation with photon techniques. As such, proton beam therapy for six weeks is not likely to be more beneficial than other standard modalities for treatment of this patient. Therefore, for the reasons stated above, the requested services are not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 23-year-old female enrollee has requested reimbursement for genotype testing performed on 11/10/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees behavioral health conditions. The physician reviewer found that the documentation indicates that the patient has a history of mood and anxiety problems.  She also reported a significant history of substance use. The submitted records do not indicate past medication trials which the patient has attempted for her psychiatric conditions. It appears that the patient has attempted non-medication treatment, such as psychotherapy, but details of this were not provided. It is not clear that the patient has had cognitive behavioral therapy for her major depressive disorder or generalized anxiety disorder diagnoses.  It is not clear that the patient has tried other forms of psychotherapy that have been shown to be effective for her diagnoses. Cognitive behavioral therapy is a first-line treatment for the patients conditions. Thus, genotype testing performed on 11/10/17 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 47-year-old female enrollee has requested authorization and coverage for treprostinil (Orenitram) tablets. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees pulmonary arterial hypertension. The physician reviewer found the U.S. Food and Drug Administration (FDA) indicates that Orenitram is a prostacyclin vasodilator indicated for treatment of PAH with WHO Group 1 to improve exercise capacity. The study that established effectiveness included predominately patients with WHO functional class II-III symptoms. This patient has been diagnosed with PAH consistent with WHO Group 1, NYHA functional class III. The patient underwent reactive testing, which was consistent with the etiology of PAH. The patient underwent the appropriate testing and was considered to be a candidate for Orenitram. All told, Orenitram is FDA approved for treatment of this patients medical condition and the literature supports the requested therapy for use in this clinical setting. Thus, the requested Orenitram is medically necessary for treatment of this patients PAH. Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 37-year-old male enrollee has requested reimbursement for single-photon emission computed tomography (SPECT) imaging (CPT 78607) provided on 2/22/17 and 2/23/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees behavioral health conditions.  The physician reviewer found that SPECT is a sophisticated nuclear medicine study that examines blood flow in the brain with the assistance of a radioactive tracer that is introduced to the patients body.  Brain activity demands blood flow, so it is postulated that SPECT can provide information regarding hyperactive, suboptimal or normal functionality of specific brain structures and regions. Advances in neuroimaging techniques, such as SPECT, represent an exciting, and potentially useful, expansion of the collective knowledge base. However, the technology is still in its infancy, and meaningful correlation between clinical diagnoses and specific brain activity patterns does not yet exist. Additionally, the documentation did not indicate that first-line strategies for the treatment of mood and anxiety disorders had been exhausted. Further, it was noted that the patient had urges to associate with other women only when he drinks, but there was no discussion about the possibility of an alcohol use disorder or interventions to ameliorate that precipitating factor. In sum, considering the relevant peer-reviewed literature and current practice standards in the United States, at this point in time, SPECT is not a standard diagnostic intervention.  Further, it has not been established that the disputed neuroimaging yielded information that significantly influenced treatment decisions, improved the patients condition, prevented a more serious episode of illness or reduced the psychiatric morbidity. Thus, SPECT imaging (CPT 78607) provided on 2/22/17 and 2/23/17 was not medically necessary for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

The patient is a 55-year-old male with a history of hearing loss and vertigo which has been responsive to prednisone. He was treated with Simponi injections in August 2017. The patient has requested authorization and coverage for Simponi 50 mg injections once per month for one year (J1602). The Health Insurer has denied this request indicating that the requested medication is considered investigational. The records indicate that this patient has autoimmune hearing loss. The patient has been treated with high dose prednisone as well as Atabrine. However, there is a paucity of peer-reviewed medical literature supporting the use of tumor necrosis factor (TNF) blockers for the treatment of autoimmune hearing loss (Derebery, et al; Van Wijk, et al). Thus, the requested Simponi 50 mg injections once per month for one year (J1602) 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, the requested medication is 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 

The parent of a 14-year-old female enrollee has requested reimbursement for acute psychiatric inpatient treatment provided from 4/15/19 through 5/03/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. In terms of risk of harm, the records support a score of 5. The records documented an extreme risk of harm, due to suicidal ideation with plan and recent self-harm. With regard to functional status, the records support a score of 4. The patient had serious functional impairment due to conflict with parents and recent threats of self-harm. In terms of comorbidity, the records support a score of 1. There was no comorbidity, due to lack of substance abuse, medical concerns, or developmental concerns. With regard to stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to multiple school changes and recent trauma involving an online pedophile making threats to harm the patient and her family. In terms of environmental support, the records support a score of 2. The patient had a supportive environment due to her parents involvement in treatment and treatment planning. With regard to resiliency and treatment history, the records support a score of 5. The patient had minimal response to recent treatment, including multiple hospitalizations and residential treatment. In terms of treatment acceptance and engagement, the records support a score of 4. The patient demonstrated initial resistance to participating in treatment. Thus, the patient has a total score of 24. Due to the extreme risk of harm, medically managed residence-based services were indicated. Furthermore, due to multiple recent treatment failures with shorter hospitalizations, an extended hospitalization incorporating an extended diagnostic assessment, intensive treatment and careful treatment planning was indicated for this high-risk patient. Therefore, acute psychiatric inpatient treatment provided from 4/15/19 through 5/03/19 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 42-year-old female enrollee has requested authorization and coverage for destruction of intraosseous basivertebral nerve. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that Fischgrund and colleagues performed a randomized controlled trial regarding the two-year clinical outcomes for chronic low back pain patients treated with radiofrequency ablation of the basivertebral nerve. The authors noted, aBasivertebral nerve ablation appears to be a safe, durable, minimally invasive treatment for the relief of chronic low back pain in a patient population that typically has few effective treatment options.a Lorio and colleagues concluded, aThe procedure is supported by level 1 evidence including two randomized controlled trials demonstrating a statistically significant decrease in pain and an improvement in function with outcomes sustained to at least 24 months in a limited number of studies.a In this case, the patient has had a history of chronic low back pain that has persisted for several years, which has been refractory to multiple modes of standard care. Based on the available medical records for review and the current studies, the requested services are likely to be superior over other treatment options. Thus, destruction of intraosseous basivertebral nerve is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

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 the Decision Dx Assay tests the tissue genetics of the melanoma and can stratify whether a thin melanoma is high risk for metastasis or not. The patients provider recommended Decision Dx where the genes are examined for certain markers and then the lesion can be further stratified to tell if it is high risk for metastasis. This test has shown some accuracy in thin melanomas like this patients. However, the treatment of this patient would not change based on the results of the testing. Moreover, the testing at issue is not the standard of care. There is a lack of peer-reviewed literature to support its use in the care of patients with thin melanomas to effect health outcomes. Given the lack of support in the peer-reviewed literature, 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 64-year-old female with a history of chronic right knee pain due to osteoarthritis. The patient has requested reimbursement for Hyaluronan injections provided on 11/05/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that an exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patientas options were limited. She had tried and failed other conservative treatments, including bracing and medication, with the alternative being a total knee arthroplasty. Therefore, Hyaluronan injections provided on 11/05/20 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 48-year-old female enrollee has requested reimbursement for laparoscopic gastric sleeve (CPT 43775) performed on 12/17/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees morbid obesity. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  This patient is an adult with morbid obesity.  Per the records, her body mass index was greater than 40 kg/m2 (it was 44.9 kg/m2). The patient documented prior dietary efforts and completed a multidisciplinary evaluation that did not reveal any obvious medical, dietary or behavioral barriers to surgery. The patient met standard nationally accepted criteria for bariatric surgery.  The current medical evidence supports the services at issue in this clinical setting.  All told, laparoscopic gastric sleeve performed on 12/17/15 was medically indicated for the treatment of this patient.  Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 39-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 9/6/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees breast examination. The physician reviewer found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis performed on 9/6/16 was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Based upon the information set forth above, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 49-year-old female enrollee has requested reimbursement for Tempus xT gene panel performed on 3/16/20.  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 individualized molecular tumor profiling holds the promise of enabling personalized selection of molecularly targeted treatment based on the specific genotype identified. Several platforms are available, including the Tempus gene panel. The National Comprehensive Cancer Network guidelines recommend tumor molecular testing prior to initiation of therapy for recurrent or persistent ovarian cancer, if not previously done. Molecular profiling is now considered a standard of care in patients with recurrent or persistent ovarian cancer. There is sufficient support for the services at issue in this clinical setting. Therefore, the Tempus xT gene panel performed on 3/16/20 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 63-year-old female enrollee has requested reimbursement for laboratory testing (collagen crosslink testing) performed on 12/03/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has been diagnosed with osteoporosis. The physician reviewer found that bone mineral density (BMD) assessment, via dual-energy x-ray absorptiometry (DEXA) is still the criterion standard for evaluation and diagnosis of osteoporosis. However, because changes in bone mass and density in response to antiresorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover may be a useful adjunct in monitoring of osteoporotic patients treated with antiresorptive agents. The medical evidence suggests that biochemical markers could be useful in making therapeutic decisions because, in general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine. There is sufficient support for the services at issue in this clinical setting. All told, laboratory testing (collagen crosslink testing) performed on 12/03/16 was likely to have been more effective 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 3


A 68-year-old female enrollee has requested DecisionDX melanoma assay test performed on 6/19/15.  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 this patient has a rare disease, ocular melanoma, which has a poor prognosis once it metastasizes.  However, knowledge of the propensity for metastasis directly affects surveillance of patients by computed tomography (CT) scan.  The gene expression classifier DecisionDX defines two classes of ocular melanoma. Class I is associated with a low risk of metastasis and class 2 has a 50% risk at two years and 72% risk at five years.  There is no other standard prognostic indicator that could serve as an alternative. Thus, the current medical evidence favors the use of this test in the postoperative surveillance of patients with ocular melanoma.  In sum, the DecisionDX melanoma assay test was likely to have been of greater efficacy 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.