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

Summary Reviewer 1

A 47-year-old female enrollee has requested reimbursement and prospective authorization and coverage for pertuzumab injections from 8/18/15 forward. The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees medical condition. The physician reviewer found pertuzumab is a monoclonal antibody that targets HER2 positive breast cancer cells, similar to, but not exactly in the same way as trastuzumab.  In metastatic breast cancer, when used in combination with chemotherapy and trastuzumab, pertuzumab yields superior progression-free survival compared to treatment with Taxotere-Herceptin without pertuzumab.  Combining pertuzumab with Herceptin and chemotherapy also appears to be superior to the combination without pertuzumab in the neoadjuvant situation.  However, there is a lack of data to support the use of combining pertuzumab with trastuzumab in the adjuvant setting.  Therefore, the superior efficacy of pertuzumab injections from 8/18/15 forward has not been established.  Based upon the information set forth above, the services at issue were not and 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: Overturned

Summary Reviewer 1 
 
A 30-year-old female enrollee has requested authorization and coverage for Xeljanz 5 mg tablet. 
The Health Insurer has denied this request and reported that the requested medication is 
investigational for the treatment of the enrollees medical condition. The physician reviewer 
found that there are no FDA approved medications for the treatment of alopecia areata. 
Commonly used treatments have included off-label use of steroids and steroid sparing drugs like 
methotrexate as well as topical agents and topical immunotherapy with squaric acid (which 
cannot be use for practical reasons on the eyelids). There are many Janus kinase inhibitors 
currently in phase 3 trials and many more patients that are using this treatment off-label with 
good success for this disease.  There is sufficient support for the requested medication in this 
clinical setting. Therefore, Xeljanz 5 mg tablet is likely to be more beneficial than any available 
standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 12-year-old male enrollee has requested authorization and coverage for Humatrope 12 mg cartridge. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees growth hormone deficiency. The physician reviewer found the requested medication is medically necessary for treatment of the patients medical condition. The patient has experienced a deceleration in growth velocity from the 40th percentile to fifth percentile between 2-11 years of age. IGF-1 level was low, and provocative GH testing results were poor. Based on auxological and biochemical criteria, the patient meets generally established guidelines for GH treatment. He had a good response to one year of therapy without adverse effects, and continuation of GH therapy is medically necessary until epiphyseal fusion. Withdrawal of therapy at the age of expected puberty may result in irreversible impairment in height potential. As such, Humatrope 12 mg cartridge has been established as medically necessary for treatment of the patients medical condition. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 41-year-old male enrollee has requested reimbursement for Decision DX Melanoma Assay performed on 12/16/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. 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 they suggest a high-risk for the development of metastatic disease in the future.  Such patients may be observed or treated with interferon-alpha.  There is little data on the services at issue in this clinical setting.  The test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques.  Thus, Decision DX Melanoma Assay performed on 12/16/15 was not likely to be more effective 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: Overturned

Summary Reviewer 3


The parent of an 11-year-old male enrollee has requested reimbursement for the Prometheus Anser IFX test performed on 7/16/14. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis.   The physician reviewer found that in the current peer-reviewed medical literature, Yanai and Hanauer concluded that although the incorporation of the measurement of trough levels and anti-drug antibodies may be helpful in this clinical setting, prospective controlled trials are direly needed to investigate the optimal tailored management in individual patients who lose response. The testing for trough IFX levels and antibodies are appropriate and within the accepted standard of practice now in patients treated with IFX. The Anser IFX testing in this patients case was non-trough. All told, the mid treatment Anser IFX lab test performed on 7/16/14 was not likely to be more beneficial for evaluation of this patients ulcerative colitis than any available standard testing. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 26-year-old male enrollee has requested reimbursement for the substance use residential treatment services provided from 11/11/14 through 11/19/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse.  The physician reviewer found that the records indicate that this patient was not at imminent risk for withdrawals. He was not suicidal or homicidal and he was not aggressive towards others. He did not show self-harm behaviors. He was cognitively intact and able to perform activities of daily living. He was medically and psychiatrically stable. He was motivated and a willing participant in his recovery. While he remained at risk for relapse, he had improved and treatment could have been managed at a lower level of care. By 11/11/14, he no longer required 24-hour supervision and could have been stepped down to a lower level of care such as intensive outpatient. For these reasons, the substance use residential treatment services provided from 11/11/14 through 11/19/14 were not medically necessary for treatment of this 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: Overturned

Summary Reviewer 3


A 62-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 4/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found according to Helvie, The Achilles heel of screening mammography is the detection of cancer in women with radiographic dense breasts. While nearly all cancers will be apparent in fatty breasts, only half will be visible in extremely dense breast. This results, at least in large part, from the masking or camouflaging of noncalcified cancers by surrounding dense tissue. The author further states that breast tomosynthesis has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies. In this case, the patient presented with heterogeneously dense breasts. Given the dense nature of the patients breasts, the breast tomosynthesis performed on 4/23/15 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities.  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 2

A 67-year-old male enrollee has requested reimbursement for gene testing performed on 4/19/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees metastatic renal cell carcinoma. The physician reviewer found the National Comprehensive Cancer Network guidelines list numerous first-line and second-line treatment options for clear cell kidney cancer (renal cell cancer.) These include temsirolimus and everolimus. None of them require genetic testing. The discussion section of the guidelines do not mention the use of next generation sequencing such as FoundationOne testing. There is a proposed clinical trial evaluating next generation sequencing that will include kidney cancer patients. It is not yet accruing patients. At this time, there is a lack of data to support that gene testing performed on 4/19/16 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 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 a 14-year-old male enrollee has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment center (RTC) services provided from 11/7/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees attention deficit hyperactivity disorder (ADHD) and anxiety. The physician reviewer found that based on current guidelines including the Child and Adolescent Level of Care Utilization System (CALOCUS), the RTC services provided from 11/7/16 forward were not and are not medically necessary for treatment of this patients medical condition. As noted by the CALOCUS, the patient was at some risk of harm due to episodic outbursts but is not having active suicidal ideation or other behaviors or thoughts. In addition, the patients functional status is moderate, the patient has had minimal school disruption and is able to complete activities of daily living in an age appropriate manner. Further, the patient does not have active serious medical problems and although he has issues with family relationships, he has a stable housing situation if accepted home. The patients resiliency and treatment history is moderate due to minimal positive treatment response in the past and the patient participates actively in therapy but has poor insight and is obstructive at times. Overall, this patients presentation supports treatment in a less restrictive setting such as intensive outpatient program (IOP). It appears that the patient has sufficiently stabilized to allow transition to a less restrictive setting. The majority of the patients current issues are due to continued oppositional behaviors and the patient has made progress related to his treatment goals. The patients goals are similar to those that would occur on an outpatient basis. Accordingly, the medical records do not support the medical necessity of the RTC services provided from 11/7/16 forward for treatment of this patients behavioral issues. Based on the available documentation, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 53-year-old female enrollee has requested authorization and coverage for durable medical equipment (Flexitouch pneumatic compression pump and leg garment).  The Health Insurer has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees lymphedema of the left leg. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the requested equipment. According to Oremus and colleagues there are several conservative (non-pharmacologic, nonsurgical) treatments that exist for secondary lymphedema, however the optimal treatment is unknown. Oremus and colleagues examined the effectiveness of conservative treatments for secondary lymphedema, as well as harms related to these treatments. The authors concluded The literature contains no evidence to suggest the most effective treatment for secondary lymphedema. According to the documentation submitted for review, the patient has been treated with CDT and use of a Medi550 Class 4 (49.0 mmHg) compression garment. However, the patient has not failed treatment with a single chamber non programmable pump which is the next of treatment for the patients medical condition. For the reasons provided, the requested equipment 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 3 
  A 37-year-old male enrollee has requested reimbursement for laboratory testing performed on 
6/05/20. 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 for primary cutaneous lymphoma (including mycosis fungoides), the most recent 
NCCN guidelines state that T-cell receptor analysis is useful to support the diagnosis of mycosis 
fungoides  and  to  distinguish  mycosis  fungoides  from  other  inflammatory  dermatoses.  In 
addition, demonstration of identical clones in the skin, blood, and/or lymph nodes may be helpful 
both for diagnosis and differentiating mycosis fungoides and Sezary syndrome from benign 
inflammatory skin diseases, and blood testing is useful to identify blood involvement, which is 
critical for staging purposes. The patient had noticed a skin lesion in 2018 and was diagnosed 
with mycosis fungoides stage IB in 2018 at UC Irvine; he was originally diagnosed with mycosis 
fungoides at age 22 in China. On the examination of 4/16/20, he was noted to have patchy 
erythema by his provider, who was unsure if this represented underlying cutaneous lymphoma 
versus other process. As he had lost insurance, biopsy was deferred. On subsequent examination 
on 6/04/20, he again had patchy erythema and had biopsies taken and blood taken for ClonoSeq 
ID (T-cell receptor analysis). Biopsy results from 6/04/20 were consistent with mycosis fungoides 
of the skin. T-cell clonality studies from the skin showed dominant TCR beta and TCR gamma 
sequences, providing support for a clonal process.  NCCN guidelines for mycosis fungoides 
highlight the importance of identifying TCR clones in skin and blood for staging purposes (in this 
case to ensure that the staging had remained the same versus changed for the patient with 
known history of mycosis fungoides). Therefore, laboratory testing performed on 6/05/20 was 
likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a seven-year-old male enrollee has requested reimbursement and prospective authorization and coverage for applied behavior analysis (ABA) (36 hours of 97153 and 6 hours of 97155) provided from 3/03/20 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the patient meets all medical necessity criteria defined by Papatola and Lustig. The authors noted that medical necessity is defined as health-care services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. The Health Insurer has indicated that the services at issue were not and are not medically necessary because they are educational in nature. While the services are provided in an educational setting (which the BACB encourages), the patient is working on goals related to his autism diagnosis, not goals that are intended to improve their academic performance. These goals include maladaptive behavior, receptive/expressive language, pragmatic language, social skills, self-help, and safety, all of which are associated with autism spectrum disorder. All of the goals highlight developing independence in association with the patients specific autism symptoms. Therefore, ABA services (36 hours of 97153 and 6 hours of 97155) provided from 3/03/20 forward were and are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 60-year-old male has requested reimbursement for gene testing provided on 11/07/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by the staging system spelled out by Balch. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either class 1 or class 2 based on the risk of metastasis. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear if DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, gene testing provided on 11/07/17 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 28-year-old female enrollee has requested reimbursement for mental health residential treatment provided from 10/18/18 through 2/12/19. 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 in cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate 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 or homicidal ideation or self-harm. With regards to functional status, the records support a score of 2 due to some difficulty meeting obligations and disruptions in usual activities. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to stable medical issues and no active substance use. With regards to level of stress of the recovery environment, the records support a score of 2 due to recent move back in with parents. In terms of level of support of the recovery environment, the records support a score of 2 due to positive relationship with family overall and parents ability to aid her. With regards to treatment and recovery history, the records support a score of 3 due to no significant recent intensive forms of treatment prior to her residential admission and unclear response to prior treatment. In terms of engagement and recovery status, the records support a score of 3 due to variability in cooperation in treatment and limited insight into the need for treatment. The patient has a composite score of 15. This score of correlates with high intensity community-based services. Therefore, residential treatment was not medically indicated. Thus, mental health residential treatment provided from 10/18/18 through 2/12/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 49-year-old female who developed shoulder pain and left leg atrophy. The patient has requested authorization and coverage for Rituxan (rituximab intravenous solution 500 mg/50 mL). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The patient was diagnosed with an inflammatory neuropathy for which Rituximab was requested after intolerance to IVIG. Rituximab is a reasonable alternative in this case. The medical literature includes several studies and reports that support the efficacy of Rituximab in CIDP and CIDP variants. Therefore, Rituxan (rituximab intravenous solution 500 mg/50 mL) is medically necessary for the treatment of this patient.