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

Summary Reviewer 1

A 54-year-old female enrollee requested authorization and coverage for arthrodesis sacroiliac joint percutaneous. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees bilateral sacroiliitis. The physician reviewer found Evidence based medical guidelines support SI joint fusion (either open or percutaneous) on a case by case basis as a last line of therapy for the following conditions, with ongoing symptoms, corroborating physical examination findings and imaging, and after failure of non-operative treatment: SI joint infection, tumor, disabling pain due to sacroiliitis due to spondyloarthropathy, sacroiliac pain due to severe traumatic injury, and in conjunction with multisegmental spinal constructs. The International Society for Advancement of Spine Surgery (ISASS) policy statement for minimally invasive sacroiliac joint fusion provides specific indications for surgery. The ISASS criteria include significant sacroiliac joint pain or significant limitations in activities of daily living because of sacroiliac joint pain; sacroiliac joint pain confirmed by at least three positive sacroiliac joint provocative tests; confirmation of the sacroiliac joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular sacroiliac joint block in the immediate post-injection period; failure to respond to at least six months of non-surgical treatment including medications, rest, physical therapy, and sacroiliac joint steroid injection or rhizotomy; and, additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been clearly considered, investigated and ruled-out. This patient presents with persistent and unremitting bilateral SI joint pain, right greater than left. Significant functional difficulty has been documented in activities of daily living. She reported an onset of pain relative to a fall from counter height onto her buttocks in August 2015. There is evidence of long term conservative treatment including medications, activity modification, SI joint injections, and physical therapy without sustained improvement. Clinical examination findings have documented bilateral SI joint tenderness with at least three positive sacroiliac provocative tests. Bilateral SI joint injections have been documented with 75-80% short term pain relief. In this patients case, current evidence based medical guideline and peer-reviewed surgical indications for SI joint fusion have been met. All told, arthrodesis sacroiliac joint percutaneous is 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 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 1

A 49-year-old female enrollee has requested reimbursement for Guardant360 CDx testing performed on 3/22/21. 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 inoperable advanced pancreatic cancer is an incurable disease, but chemotherapy can prolong survival. The genetic mutations that are present can provide prognostic significance and can help direct therapy. Mutational analysis is also part of the algorithms that are included within the National Comprehensive Cancer Network (NCCN) guidelines, but this is restricted to testing on the primary tumor samples. According to the NCCN guidelines, aGermline testing is recommended for any patient with confirmed pancreatic cancer, using comprehensive gene panels for hereditary cancer syndromes. Genetic counseling is recommended for patients who test positive for a pathogenic mutation or for patients with a positive family history of cancer, especially pancreatic cancer, regardless of mutation status.a According to the NCCN guidelines, aTesting on tumor tissue was preferred; however, cell-free DNA testing can be considered if tumor tissue testing is not feasible.a The NCCN guidelines goes on to say, aData are not available to show that earlier treatment of recurrences, following detection by increased tumor marker levels or CT scan, leads to better patient outcomes.a The Guardant360 test is a liquid biopsy that analyzes patient plasma for mutations in a panel of 70 genes. In this case, Guardant360 CDx testing was not done to analyze mutational analysis of an existing recurrence or an existing mass. Instead, it was performed to look for recurrence. This is not a medically appropriate use of the test. Therefore, Guardant360 CDx testing performed on 3/22/21 was not likely to have been more beneficial for evaluation of the patientas condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 46-year-old male enrollee has requested authorization and coverage for an oral appliance. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees mild obstructive sleep apnea. The physician reviewer found that the submitted documentation supports the medical necessity of the requested device. The patient has been diagnosed with mild obstructive sleep apnea. Per the records, treatment with CPAP was initially recommended. The clinical notes indicate that the patient is unable to tolerate CPAP therapy. For patients who are unable to tolerate CPAP therapy, treatment with an oral appliance has been shown to improve symptoms of obstructive sleep apnea. The medical evidence supports the requested device in this clinical setting. Thus, the requested oral appliance is medically necessary for the treatment of this patient. Therefore, the requested device is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 17-year-old female enrollee has requested reimbursement and prospective authorization and coverage for eating disorder residential treatment center (RTC) services provided from 2/19/18 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 eating disorder. The physician reviewer found that the records provided for review document that this patient presented for admission from another facility with a low BMI. The patients prior care was not adequate to stabilize her weight loss such that she had lost 20 pounds in two months while in treatment. During the beginning of her stay, the patient continued to have difficulty with gaining weight and completing her meals. She required staff supervision and one-to-one care in order to finish her meals. She also required supplementation with liquid dietary supplements and order to maintain her calorie requirements. She was noted to be depressed, withdrawn and minimally interactive with staff and peers. As her treatment has progressed, she has gained weight, but some of her mood symptoms have not resolved. Give this patients history, it is unlikely that less restrictive treatments would be effective for her eating disorder treatment. In the medical literature, Mehler noted that anorexia nervosa is a psychiatric disorder characterized by abnormal eating behaviors that results in weight loss and has serious potential medical consequences. Due to this patients history of mood symptoms, self-harm, suicide attempts, and severe eating disorder behaviors, the eating disorder residential treatment center services provided from 2/19/18 forward were and are medically necessary. Based on the foregoing discussion, 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 50-year-old male enrollee has requested authorization and coverage for Vemlidy. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B. A review of the record indicates the enrollee has a history of hepatitis B. On 5/9/17, the enrollee was noted to have hepatitis B complicated by cirrhosis. The record indicates the enrollee has been treated with Viread 300 mg daily. At that time, the provider recommended treatment with Vemlidy which has a better renal and bone safety profile than Viread. The Health Insurer indicates the requested medication is not medically necessary for treatment of the enrollees medical condition. At issue is whether the requested medication is medically necessary for treatment of the enrollees medical condition.I have determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The parent of a 12-year-old female enrollee has requested authorization and coverage for surgery (ApiFix procedure). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. At issue is whether the requested services are likely to be more beneficial for treatment of the enrollees condition than any available standard therapy. The physician reviewer found that this patient was diagnosed with scoliosis when she was nine years old. At the time, her curve was only 10 degrees. Recently, the patient has had a growth spurt. Despite bracing, the curve has grown. The patient and her family are requesting a growth friendly modulation surgical approach and would like to avoid permanent fusion. The current medical evidence supports the requested services in this clinical setting. The ApiFix procedure is backed by nine years of clinical experience. There is substantial clinical experience and evidence now showing the validity and its efficacy in adolescent idiopathic scoliosis. Therefore, the requested surgery (ApiFix procedure) is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2   
The parent of a five-year-old male enrollee has requested reimbursement for immunoglobulin G 
(IgG) food testing performed on 9/27/21. The Health Insurer has denied this request and 
reported that the services at issue were investigational for the evaluation of the enrollees 
medical condition. The physician reviewer found that food-specific IgG level does not predict 
food hypersensitivity and may actually be a marker of earlier development of tolerance. Food-
specific IgG tests typically yield multiple positive results and may represent a normal immune 
response to food. In one study, children with atopic dermatitis and egg and/or milk allergy who 
had higher levels of IgG4 to milk and egg proteins were more likely to be tolerant to these foods 
by 4.5 years of age compared with children with lower IgG4 levels. In another study, resolution 
of cows milk allergy was associated with increasing IgG4 level. In addition, IgG4 increased in 
patients who successfully underwent oral immunotherapy for milk or peanut allergy. Therefore, 
food-specific IgG should not be used as a tool to diagnose food allergy, and the positive food 
should not be eliminated from the diet based upon results of these tests. Use of food-specific IgG 
level does not predict true food hypersensitivity. The standard evaluation of food allergy consists 
of blood immunoglobulin E (IgE) level for foods and skin testing. IgE immunoassays are in vitro 
assays  used  to  identify  food-specific  IgE  in  the  serum.  These  tests  are  widely  available. 
Immunoassays have demonstrated very high positive predictive accuracy in children for several 
of the major food allergens. Values have been established for egg, milk, peanut, tree nuts, and 
fish that correspond to a positive predictive accuracy of 95 percent.  Skin testing for food-specific 
IgE is used in the diagnosis of IgE-mediated food allergies.  A positive skin test to a particular food 
indicates the possibility that the patient has a true allergy to that food. A negative skin test result 
indicates the absence of an IgE-mediated allergy upon subsequent challenge with a 90 to 95 
percent predictive accuracy. Therefore, IgG food testing performed on 9/27/21 was not likely to 
have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 64-year-old female has requested reimbursement for DecisionDx-Melanoma assay provided on 3/21/18. 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 the prognosis of cutaneous melanoma has classically been determined by the applying the staging system spelled out by Balch. Mitotic index may add to these statistics. DecisionDx-Melanoma assay 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 and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma assay classification, in patients undergoing sentinel lymph node biopsy. At this time, it is not clear how the five-year data from DecisionDx-Melanoma assay compares to the ten-year data from Balch. It is also not clear if one can use the assay to make clinical decisions. Therefore, DecisionDx-Melanoma assay provided on 3/21/18 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 3

A 61-year-old female enrollee has requested reimbursement for the office visits provided on 5/20/16, 8/25/16, and 11/17/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees hypothyroidism, Hashimotos thyroiditis, menopause syndrome, and iron deficiency anemia. The physician reviewer found that meta-analysis of randomized clinical trials shows no advantage of T4 and T3 combination therapy over T4 monotherapy (Grozinsky-Glasberg, et al). This patients records do not include documentation of trial and failure or contraindication to the available formulary alternatives for management of hypothyroidism (Jonklaas, et al). Due to lack of clinical documentation, detailed physical examination findings, history of present illness, and clinical documentation to support an indication of specialty services, the office visits provided on 5/20/16, 8/25/16, and 11/17/16 were not likely to be more beneficial for evaluation of the patients medical condition than any available standard services. 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 
A 63-year-old female enrollee has requested reimbursement of liquid CDx laboratory testing by 
FoundationOne on 4/29/22. The Health Insurer has denied this request and reported that the service 
at issue was investigational for the evaluation of the enrollees lung cancer. At issue is whether 
CDx laboratory testing by FoundationOne on 4/29/22 was likely to have been more beneficial for 
evaluation of the enrollee's condition than any available standard therapy. The physician reviewer 
found that Metastatic adenocarcinoma of the lung is an incurable disease, but many advances have 
been made with targeted therapies to help extend survival. Multiple guidelines including by the 
NCCN,  College  of  American  Pathologists  (CAP),  American  Society  of  Clinical  Oncology 
(ASCO), and European Society for Medical Oncology (ESMO), recommend testing for mutations 
such as epidermal growth factor receptor (EGFR), KRAS, anaplastic lymphoma kinase (ALK), 
and c-ros oncogene (ROS1) on tumor samples to help direct therapy options. If patients are not fit 
for biopsy, or if the tissue sample is insufficient for testing, then cell-free testing may help identify 
mutations.  Cell-free tests, such as the FoundationOne CDx liquid test at issue, are very specific 
but not as sensitive as tissue testing for mutations and are not a substitute when appropriate tissue 
can be obtained. In this case, notes dated 7/27/22 reported that the patient underwent a repeat 
biopsy on 4/12/22 by EBUS to confirm recurrent disease. Molecular testing and FoundationOne 
CDx liquid testing were requested from this sample at the same time. In this clinical setting, given 
that the tissue sample is considered more sensitive/specific than liquid biopsy and is the standard 
for diagnostic management, the service at issue was not likely to have been more beneficial than 
the standard management. Therefore, CDx laboratory testing by FoundationOne on 4/29/22 was 
not likely to have been more beneficial for evaluation of the patients condition than any available 
standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 55-year-old female enrollee has requested authorization and coverage for Cambia 50 mg powder packet. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees migraine without aura. The physician reviewer found that Cambia is a powdered form of diclofenac which has been shown to be effective in treating acute migraine. This patients provider states that the patient is unable to use tablets due to nausea. However, Cambia must also be taken orally and is not a parenteral treatment. When nausea is present, then parenteral medication such as sumatriptan nasal spray, zolmitriptan nasal spray, sumatriptan injection, or use of an anti-nausea agent with antimigraine properties such as prochlorperazine are likely to be effective. Overall, the patients records do not document that the patient has used other approved standard therapies. Therefore, the requested Cambia 50 mg powder packet is not medically necessary for treatment of this patients medical condition. Based on the available documentation, the requested medication is 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 72-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene 
expression profile assay performed on 8/30/19. 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 the prognosis of cutaneous melanoma 
has classically been determined by the analysis of Balch. Mitotic index may add a bit to these 
statistics. DecisionDx-Melanoma gene expression profile assay is a 31-gene assay of an 
individuals melanoma cells. It then places that particular melanoma into either Class 1 or 2, 
with somewhat different risks of metastasis by five years. It is not clear how the five-year 
DecisionDx-Melanoma gene expression profile assay data compares to the ten-year Balch data.  Most importantly, there is a lack of data to support using DecisionDx-Melanoma gene 
expression profile assay in making clinical decisions, such as the need for sentinel node biopsy 
and/or adjuvant therapy. Therefore, DecisionDx-Melanoma gene expression profile assay 
performed on 8/30/19 was not likely to have been more beneficial than any available standard 
therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
A 49-year-old female insured has requested authorization and coverage for thermal destruction of 
intraosseous basivertebral nerve including all imaging guidance; first two vertebral bodies, lumbar 
(CPT 64628). The insureds symptoms are having a significant impact on activities of daily living 
such as household chores, leisure activities, sleeping, and work. Medications have included 
acetaminophen,  Celebrex,  meloxicam,  naproxen,  and  muscle  relaxants.  The  Health  Insurer 
indicates the requested services are considered investigational for the treatment of the insureds 
medical condition. Therefore, the Health Plan has denied coverage for the requested treatment. 
This denial is the subject of this appeal and determination. The physician reviewer found that 
overall, the data from the current peer-reviewed medical literature on basivertebral nerve ablation 
report long-term improvement in pain and function in well selected patients. One study from 
Fischgrund  and  colleagues  reported  that  at  two-year  follow-up,  patients  treated  with  radiofrequency ablation of the basivertebral nerve for chronic low back pain exhibited sustained 
clinical benefits. The authors concluded that basivertebral nerve ablation is supported as a 
durable, minimally invasive treatment for the relief of chronic low back pain. In addition, Khalil 
and colleagues found that minimally invasive radiofrequency ablation of the basivertebral nerve 
ablation led to significant improvement of pain and function at three months in patients with 
chronic vertebrogenic related low back pain.  As low back pain is known to arise from numerous 
etiologies, careful diagnosis and patient selection for those with vertebrogenic pain as the primary 
source of symptomatology is essential for optimal outcomes. Within the records available for 
review, there is documentation of chronic low back pain described as vertebrogenic pain. The 
treating provider has recommended thermal destruction of the intraosseous basivertebral nerve. 
The medical records indicate that the patient has tried and failed multiple conservative treatments 
including physical therapy, medial branch blocks, trigger point injections, lumbar facet injection, 
and medications such as acetaminophen, Celebrex, meloxicam, and naproxen. Based on the 
support in the medical literature, the requested thermal destruction of intraosseous basivertebral 
nerve including all imaging guidance; first two vertebral bodies, lumbar (CPT 64628) is likely to 
be more beneficial for the treatment of the patients medical condition than any available standard 
therapy.