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

Summary Reviewer 3
A 47-year-old male enrollee has requested reimbursement for automated evacuation of meibomian glands performed on 2/2/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees meibomian gland dysfunction.
The physician reviewer found that according to Thode and Latkany Meibomian gland (MG) dysfunction (MGD) is a multifactorial, chronic condition of the eyelids, leading to eye irritation, inflammation and ocular surface disease. Initial conservative therapy often includes a combination of warm compresses in addition to baby shampoo or eyelid wipes. There is some evidence in the medical literature that automated evacuation of meibomian glands (LipiFlow) can be therapeutic in select patients. However, LipiFlow is a treatment of last resort in patients whose meibomian glands have not responded to standard treatments (Thode and Latkany; Satjawatcharaphong et al). In this case, there is a lack of documentation supporting that all other treatments had been tried failed. Therefore, one cannot conclude that the use of LipiFlow was clinically indicated or 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 services at issue were 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: Upheld

Summary Reviewer 1


A 65-year-old female enrollee has requested reimbursement for autonomic nerve function testing performed on 3/26/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  While autonomic testing can be useful in select cases where clear autonomic symptoms and findings have been documented, it should not be used in generic cases where a patient is noted to have pain.  In this case, the records do not clearly demonstrate marked autonomic findings or symptoms.  In the absence of this, autonomic testing has not been shown by clinical studies to statistically improve the management of patients.  The patient can be evaluated for treatable causes of peripheral neuropathies in the absence of the requested testing.  All told, autonomic nerve function testing performed on 3/26/15 was not likely to have been of greater benefit than other alternatives.  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 2

A 42-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/29/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the 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. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. This test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy. In sum, DecisionDx-Melanoma testing performed on 8/29/18 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 60-year-old male enrollee has requested reimbursement for Oncotype DX prostate cancer assay (CPT code 84999) testing provided on 4/11/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees elevated prostate-specific antigen (PSA). The physician reviewer found that once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features such as the grade of tumor and PSA level. This helps guide the most appropriate therapy for patients taking into account their age and co-morbidities. The Oncotype DX prostate cancer assay is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score (GPS). A validation study was presented at the American Urological Association meeting in 2013 involving 395 patients (Cooperberg, et al; Eastman). The GPS identified patients that had very low risk disease that could be followed rather than referred for surgery. The Oncotype DX is a medically appropriate to better stratify patients with localized disease. All told, the Oncotype DX prostate cancer assay (CPT 84999) testing performed on 4/11/16 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 testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1 
 
A 63-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene test 
(CPT 81529) performed on 5/27/21. 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 the use of gene expression profiling (GEP) testing according to 
specific American Joint Committee on Cancer (AJCC) melanoma stage, before or after sentinel 
lymph node biopsy (SLNB), requires further prospective investigation in large, contemporary data 
sets of unselected patients. Prognostic GEP testing to differentiate melanomas at low-risk versus 
high-risk for metastasis should not replace pathologic staging procedures. Moreover, since there 
is a low probability of metastasis in melanoma in stage I and a higher proportion of false-positive 
results, GEP testing should not guide clinical decision-making in this subgroup. Therefore, the 
DecisionDx-Melanoma gene test (CPT 81529) performed on 5/27/21 was not likely to have been 
more beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 59-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/9/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination. The physician reviewer found that the Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  However, in this patients case, there were no problems to be resolved.  The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications.  In this clinical setting, a routine mammogram would have been sufficient.  Digital breast tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality. Therefore, breast tomosynthesis performed on 8/9/16 was not likely to have been of greater benefit than other modalities for evaluating this patient. Based upon the information set forth above, the service at issue was not likely to have been 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 1


A 51-year-old female has requested reimbursement for human epididymis protein 4 (HE4) testing.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this patients case.  HE4 is used for the evaluation of an adnexal mass as a component of the Risk of Ovarian Malignancy Algorithm (ROMA). A ROMA score helps determine the likelihood that an adnexal mass is malignant and the need for referral to a gynecologic oncologist for surgery. This testing is considered a standard of care.  In sum, HE4 testing performed on 11/20/15 was likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 33-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 4/30/15. 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 in this patients case, Anser IFX testing was used to obtain drug levels of Remicade to guide dosing.  When the level came back high on 4/30/15, the dose was lowered to every seven weeks with the plan to go to every eight weeks if the level remained high. The single clinical note does not indicate the patient had or was failing therapy.  There is a lack of controlled data to support Remicade therapy guided through serial drug level assessments.  All told, the superior efficacy of Anser IFX testing performed on 4/30/15 has not been established.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3 
A 36-year-old female insured has requested reimbursement for laser hair removal performed on 
10/25/22. A review of the record indicates that the insured was diagnosed with hidradenitis 
suppurativa at the axillae and groin two years ago, which worsened with pregnancy. The Health 
Insurer indicates the services at issue were considered investigational for the treatment of the 
insured's medical condition. Therefore, the Health Insurer has denied reimbursement for the 
services at issue. This denial is the subject of this appeal and determination. The physician reviewer 
found that as noted in the current peer-reviewed medical literature, laser hair removal is not 
supported as a first-line treatment for patients with hidradenitis suppurativa. According to Alikhan 
and  colleagues,  several  treatment  options  are  indicated  for  the  treatment  of  patients  with 
hidradenitis suppurativa including antibiotic combinations with metformin, adalimumab, and 
surgery. Specifically, adalimumab is FDA-approved and likely to be more effective for the 
treatment of patients with hidradenitis suppurativa than laser hair removal. The records provided 
for review indicate that this patient underwent laser hair removal for the treatment of his chronic 
hidradenitis suppurativa. However, the medical literature has established adalimumab as a more 
effective treatment option. Therefore, the laser hair removal performed on 10/25/22 was not likely 
to be more beneficial for the treatment of the patients condition than any available standard 
therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 39-year-old female enrollee has requested reimbursement for Prometheus Anser ADA testing performed on 1/27/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that based upon the medical records provided, the Prometheus Anser ADA testing performed on 1/27/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Maximizing the efficacy of therapies, for inflammatory bowel disease (IBD), while minimizing their toxicity remains the principal objective in developing management strategies for IBD patients. Recognition of the factors influencing therapeutic response allows clinicians to individualize dosing regimens to meet this objective. In order to optimize IBD therapy, it is critical that prescribers understand that standard dosing is insufficient for most patients, given the interindividual variability relating to response and tolerability. The loss of response to adalimumab can be due to subtherapeutic infliximab/adalimumab levels or the presence of antibodies to infliximab/adalimumab. The available data suggest that measuring drug and/or antibody levels could help clinicians to optimize anti-tumor necrosis factor (TNF) therapy by adjusting drug doses or switching to alternative therapies in patients who are unlikely to respond to continued treatment with a particular agent. Prometheus Anser ADA diagnostic test is considered safe and effective in optimizing therapy in patients with inflammatory bowel disease such as Crohn's disease who are being treated with anti-TNF agents such as Humira and infliximab. In this case, Prometheus Anser ADA assay was likely more beneficial than empiric dose escalation of Humira in this patient with suspected flare-up of her Crohns disease. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 58-year-old female enrollee has requested reimbursement for MammaPrint testing performed on 1/21/14. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for the evaluation of the enrollees breast cancer. The physician reviewer found currently, OncotypeDx is the standard of care to determine recurrence risk and need for chemotherapy in women with early stage breast cancer (Foukakis and Bergh; Harris, et al). MammaPrint (or the Amsterdam 70 gene profile) offers prognostic information and is U.S. Food and Drug Administration (FDA) approved. However, there are low quality data to show MammaPrint has clinical utility. At present OncotypeDx is considered the standard of care and MammaPrint cannot be considered a more beneficial test. For the reasons provided, the testing at issue 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 1

A 46-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 1/21/15. 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 the addition of digital breast tomosynthesis to screening diagnostic mammograms has gained wide acceptance by providers. This is due to the tomographic features of this particular technique allowing providers to eliminate overlapping tissue and gain a clearer picture of the breast parenchyma which in turn has led to increased detection of small cancers and a decrease in callbacks. For this reason the addition of the technique to the mammographic views is likely to be of more benefit to the patients than digital mammography alone. As such, the services at issue were likely to be more beneficial than 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 3 
 
A 19-year-old female enrollee has requested reimbursement for a Papanicolaou (Pap) smear 
performed on 1/03/22. 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 submitted documentation fails to demonstrate the superior efficacy of 
the services at issue. Currently, the recommendation is to begin cervical cancer screening at age 
21 in otherwise healthy women. The records do not demonstrate that a Pap smear was indicated 
in this patient at age 19. A pelvic examination is also not required in an asymptomatic patient for 
sexually transmitted disease screening or renewal of contraception. Therefore, the Pap smear 
performed on 1/03/22 was not likely to have been more beneficial for evaluation of the patient 
than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1
A 45-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 10/22/15. 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 that there is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. Due to the advantage tomosynthesis has brought to radiologists, particularly in cases of extremely and heterogeneously dense tissue such as the case under review, the American College of Radiology (ACR) has urged the technique be removed from the investigational category.  In particular, tomosynthesis has resulted in a decrease in callbacks and increase in detection of small cancers. In this case, the addition of tomosynthesis was likely of more benefit to this patient than had the exam been done with two-dimensional (2D) technique only. 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 2

A 35-year-old female enrollee has requested reimbursement for the three-dimensional (3D) mammogram provided on 10/31/16. The Health Insurer has denied this request indicating that the service at issue is considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found that 3D mammograms, also known as tomosynthesis was approved for clinical use by the U.S. Food and Drug Administration in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of mammography the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantage it brings providers interpreting mammograms especially in women with dense tissue such as the patient under review. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in overall diagnostic accuracy compared to two-dimensional mammography.  In this case, the palpable abnormality was better assessed using tomosynthesis in this patient with a strong family history and dense tissue. All told, the 3D mammogram provided on 10/31/16 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 service 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 2


A 33-year-old female enrollee has requested reimbursement for gene testing (BRAF mutation analysis) provided on 11/19/15. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees papillary thyroid carcinoma. The physician reviewer found the gene testing (BRAF mutation analysis) provided on 11/19/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The testing at issue is considered the standard of care in the evaluation of thyroid nodules. BRAF mutation analysis provides prognostic information and may help guide therapy decision making regarding use of BRAF inhibitor therapy. Identifying a marker may open other treatment options or allow for enrollment in clinical trials. Therefore, the testing at issue 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 testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 51-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 7/13/15.  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 7/13/15 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 documentation submitted for review and 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.