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

Summary Reviewer 1

A 55-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 5/29/19. 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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individualas melanoma cells. It then classifies that particular melanoma based on the five-year risk of recurrence. Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma class, in patients undergoing sentinel node sampling. 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 the DecisionDx-Melanoma data can be used to make therapeutic decisions. National Comprehensive Cancer Network discusses the use of molecular assays in the treatment of cutaneous melanoma and does not currently recommend using the assay in other than clinical trial settings. Therefore, DecisionDx-Melanoma testing provided on 5/29/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a three-year-old male enrollee has requested reimbursement and prospective authorization and coverage for nine additional weekly hours of applied behavioral analysis (ABA) therapy provided from 10/31/16 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 autism spectrum disorder. The physician reviewer found in this clinical setting, nine additional weekly hours of ABA therapy provided from 10/31/16 forward were and are medically necessary for treatment of the patients medical condition. The study by Linstead and colleagues evaluated the relationship between ABA treatment intensity and treatment outcomes for individuals with autism spectrum disorder. The authors reported a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress was demonstrated. In this case, the patient is making slow, steady progress, but continues to have significantly problematic behaviors in the areas of social skills, social-emotional awareness and safety. He is a significant flight risk with several episodes of elopement. He continues to demonstrate impairment in several areas making it increasingly difficult for him to be successful in more generalized environments. The Health Plan has 22 hours of direct ABA therapy and along with one hour per week of individual parent training and two hours of supervision per week, which is less than what is recommended for optimal response. Several studies have recommended 25 or more hours of direct weekly ABA to ensure optimal outcomes (Roane et al; Myers et al). The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30-40 hours of treatment per week. Given the support cited above, nine additional weekly hours of ABA therapy provided from 10/31/16 forward has been established as medically necessary for treatment of the patients medical condition. Therefore, the services at issue were and are 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 48-year-old male enrollee has requested authorization and coverage for cervical artificial discectomy and second level cervical discectomy.  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 that there is insufficient data to adequately assess the performance of total disc replacement. There is a lack of evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. Total disc replacement has been associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been fully documented. The standard procedure in this clinical setting is a two level anterior cervical discectomy and fusion. The proposed surgery has not been established as 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 services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 
A 19-year-old female enrollee has requested authorization and coverage for jaw surgery. The Health Insurer has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees facial pain, mastication and nasal obstruction. The physician reviewer found that the submitted documentation demonstrates the medical necessity for the requested surgery. This patient has a maxillofacial skeletal deformity which has resulted in a functional deficit. The records noted that she has difficulty with mastication, speech and has associated facial pain. Her medical condition cannot be corrected with conservative non-surgical therapy alone. Instead, this patient requires orthognathic surgery intervention to correct her maxillofacial skeletal deformity. Performance of this surgery is likely to result in improved musculoskeletal, dento-osseous and soft tissue relationships which will result in improved mastication and swallowing for the patient. The surgery has also been shown to improve the associated temporomandibular joint and associated muscular disorders. As such, the requested jaw surgery is medically necessary for the treatment of this patients medical condition. Therefore, for the reasons stated above, the requested surgery is 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 64-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 2/1/16.  The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the breast tomosynthesis performed on 2/1/16 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Ciatto and colleagues investigated the effect of integrated two-dimensional (2D) and three-dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls. Based on the medical literature cited above, the use of breast tomosynthesis was 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 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 42-year-old female who has been treated for the following conditions: low back pain; other intervertebral disc degeneration, lumbosacral region; other intervertebral disc degeneration, lumbar region; radiculopathy, lumbar; other spondylosis, lumbar region; other intervertebral disc displacement, lumbar region. The patient has requested authorization and coverage for spinal surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.  The physician reviewer found that Bydon and colleagues noted, aA trial of conservative therapy may be considered for patients with low-grade spondylolisthesis presenting with radiculopathy and/or pseudoclaudication. These options may include physical therapy, epidural steroid injection, and pain medications. If unresolved, surgical options may include decompression alone or decompression and fusion.a Chan and colleagues stated, aPatients with symptomatic lumbar spondylolisthesis may first be treated with conservative management strategies including, but not limited to, non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy. For well-selected patients who fail conservative management strategies, surgical management is appropriate.a  In this patientas case, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures prior to requested surgery to include (but not limited to) physical therapy measures. In addition, she is noted to be a daily tobacco user and notes she will quit nicotine; however, follow-up documentation does not indicate this has been completed. The provided imaging studies, including the dynamic x-rays from 8/10/21, do not corroborate movement/instability at the requested level, and detailed documentation is not evident regarding potential impending/inevitable temporary intraoperative instability. There is a lack of support for the requested services in this clinical setting. Therefore, the requested spinal surgery is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
 
A 24-year-old female enrollee has requested authorization and coverage for lower esophageal 
myotomy, transoral (peroral endoscopic myotomy) (POEM) and one inpatient day. The Health 
Plan has denied this request indicating that the requested service is investigational for the 
treatment of the enrollees medical condition. The physician reviewer found that the efficacy and 
safety of POEM has been compared with that of laparoscopic Heller myotomy (LHM). In a 
randomized trial of 221 patients with all subtypes of achalasia, POEM and LHM with Dors 
fundoplication were equally successful in controlling symptoms at two years. Compared with 
LHM, POEM was associated with a lower rate of severe adverse events (2.7 versus 7.3 %). 
Schlottmann and colleagues performed a meta-analysis of over 7,000 patients with all 3 subtypes 
of achalasia in over 70 cohort studies. The authors noted that POEM was more effective than 
LHM in relieving dysphagia. Therefore, lower esophageal myotomy, transoral POEM and one 
inpatient day is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 45-year-old female enrollee has requested reimbursement and prospective authorization and coverage for Gamunex-C from 7/01/21 forward. The Health Insurer has denied this request and reported that the medication at issue was and is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is a lack of support for Gamunex-C in this clinical setting. Damages nerves causing neuropathy can cause a wide constellation of symptoms, as they are involved in both somatic and autonomic processes. Pain is a common complaint with neuropathies as well as other forms of paresthesia. Causes of neuropathies vary from diabetes, celiac disease, hepatitis, restless leg syndrome, neurotoxic drugs, paraneoplastic syndromes, Sjogrenas syndrome, and lupus, to name a few. While there is evidence to support the possibility of efficacy of IVIG in neuropathies, it is limited at best and studies call for further investigation into its use. Therefore, Gamunex-C from 7/01/21 forward was not and is not likely to be more beneficial for the treatment of this patient than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 43-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 2/14/18. 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 this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. In sum, DecisionDx-Melanoma testing performed on 2/14/18 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 3


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 the records fail to demonstrate the superior efficacy of the services at issue.  In this clinical setting, chemotherapy and one year of trastuzumab is the standard of care. Pertuzumab is a humanized monoclonal antibody that binds to the extracellular portion of the HER2 protein. The U.S. Food and Drug Administration (FDA) has approved its use in metastatic breast cancer and in neoadjuvant treatment of HER2-positive locally advanced, inflammatory, or early stage breast cancer.  However, it is not part of regimens given postoperatively.  Furthermore, the FDA approval was based on pathologic complete response rates and not on survival criteria.  Per the current medical evidence, pertuzumab injections from 8/18/15 forward were not and are not likely to be of greater benefit than other alternatives.  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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 45-year-old male enrollee has requested reimbursement for air ambulance transport provided on 12/17/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that it is in the best interest of patient safety to transfer to the nearest appropriate facility that has the ability to best care for the injury or illness. Transfers are inherently fraught with risk, and air transfers in particular carry their own set of additional complicating factors. The determination of what is the most appropriate facility can be very complex and involves many factors, only one of which is proximity to the sending facility.  It is best left in the hands of the clinical team with hands on the patient at the time a facility is to be selected to determine what his or her needs are and, therefore, what the most appropriate facility is. This based on services, availability in the moment, proximity, reachability, family/social network, and many other factors that are only possible to determine in real time. In this patients case, ground transportation or commercial air travel were not appropriate options. The medical evidence supports the services at issue in this clinical setting. Therefore, air ambulance transport provided on 12/17/18 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 36-year-old female. The patient has requested authorization and coverage for 
NuvaRing. The physician reviewer found that at issue is whether NuvaRing is medically necessary 
for the treatment of this patient. The submitted documentation supports the medical necessity 
of the requested medication. The American College of Obstetricians and Gynecologists (ACOG) 
states, All U.S. Food and Drug Administration (FDA) approved contraceptive methods should be 
available to all insured women without cost sharing and without the need to fail certain 
methods first. In the absence of contraindications, patient choice and efficacy should be the 
principal factors in choosing one method of contraception over another." Different formulations 
of hormonal birth control may be indicated for different patients due to their symptomology and 
past medical history, and may be used for indications in addition to contraception. Generally, if 
a patient who has been stable on a brand-name medication for a significant period of time 
encounters side effects when switching to the generic formulation, continued maintenance on 
the  brand-name  version  of  the  medication  is  indicated.  Therefore,  NuvaRing  is  medically 
necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 61-year-old female enrollee has requested authorization and coverage for breath hydrogen/methane test (91065). The Health Insurer has denied this request and reported that the requested services are investigational for the evaluation of the enrollees medical condition. The physician reviewer found that breath tests are based on the principle that metabolism of a test dose of carbohydrate substrate (e.g., lactulose) by the bacterial flora leads to the production of an analyte (hydrogen, methane), which is absorbed and ultimately excreted in the breath. Lactulose is a non-absorbable substance that is normally metabolized by gut bacteria in the colon with the production of hydrogen and/or methane. In theory, in individuals without small intestinal bacterial overgrowth, the administration of lactulose results in a single peak in breath hydrogen/methane within two to three hours due to the metabolism of lactulose by colonic flora. In patients with small intestinal bacterial overgrowth, administration of lactulose results in an early peak in breath hydrogen/methane levels due to metabolism by small bowel bacteria. In reality, this test is inaccurate. The main reason is that rapid transit of lactulose can occur. This will result in the presence of an early peak, misleading one to believe the patient has small intestinal bacterial overgrowth. A double peak is often not seen in cases of true small intestinal bacterial overgrowth. Therefore, there are many false positives and false negatives. In sum, a breath hydrogen/methane test (91065) is not likely to be of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 48-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/12/17. 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 applying the staging system spelled out by Balch. Mitotic index may also add to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the risk of metastasis over five years. Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients undergoing sentinel node sampling. 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 that it can be used to make clinical decisions. Therefore, DecisionDx-Melanoma testing performed on 12/12/17 was not 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 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 57-year-old female enrollee has requested reimbursement for bilateral breast magnetic resonance imaging (MRI) performed on 7/21/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  The literature does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound.  MRI studies of the breast are highly sensitive, but have a relatively low level of specificity.  It is common for an MRI to suggest a significant lesion, at which point the patient is often subjected to ultimately unnecessary biopsies.  The medical evidence supports routine physical examinations as well as routine screening mammography as the best means to detect recurrence.  Moy and colleagues specifically addressed the issue of how to monitor patients with newly diagnosed stage 1 breast cancer.  The authors noted women newly diagnosed with stage 1 breast cancer have an early-stage disease that can be effectively treated.  Evidence provides little justification for performing imaging to exclude metastasis in asymptomatic women with stage 1 breast cancer.  No differences have been found in survival or quality of life in women regardless of whether they underwent initial workup for metastatic disease.  Moy and colleagues noted, American Society of Clinical Oncology and National Comprehensive Cancer Network guidelines state that annual mammography is the only imaging examination that should be performed to detect a localized breast recurrence in asymptomatic patients. Additional imaging may be needed if the patient has locoregional symptoms.  In this patients case, there were apparently no clinical or imaging signs of recurrent tumor.  Routine surveillance mammography and possibly breast tomosynthesis should be sufficient in this clinical setting.  All told, bilateral breast MRI performed on 7/21/15 was not medically indicated 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.