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

Summary Reviewer 1

A 60-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that the most recent National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer summarize the published literature and discuss that dosimetric comparisons studies between proton therapy and intensity modulation radiation therapy (IMRT) do not predict accurately clinically meaningful endpoints. The NCCN guidelines acknowledge ongoing clinical studies and state that there is a lack of evidence supporting a benefit or decrement to proton therapy over IMRT for either treatment efficacy or long-term toxicity. All told, the peer-reviewed medical literature does not indicate the requested proton beam radiation therapy is likely to be more beneficial for treatment of this patients prostate cancer than 
conventional alternatives. Based upon the information set forth above, I have determined 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 45-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation of the knee. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees knee pain. The physician reviewer found that surgical implantation of healthy cartilage cells (autologous chondrocyte implantation) is an alternative option for the treatment of large articular cartilage defects. Autologous chondrocyte implantation is primarily used to treat full-thickness cartilaginous defects of the distal femur by arthroscopically extracting healthy chondrocyte cells from the patients knee, culturing the cells, and implanting them back into an articular defect via an open surgical procedure. In general, autologous chondrocyte implantation is recommended as a second-line surgical option either after failure of initial arthroscopic repair or when a full-thickness articular cartilage defect is very large (2.5 cm2 or greater).  Autologous chondrocyte implantation should also be avoided in obese patients who have been shown to have no sustained improvement at two years. Worse outcomes have been reported in females with autologous chondrocyte implantation, especially in patients with patellar defects. Weak evidence has suggested some success with patellar autologous chondrocyte implantation, which remains off-label, but quality randomized controlled trials are lacking. In this patients case, the records noted a bipolar chondral lesion of the patellofemoral joint, which is a contraindication for autologous chondrocyte implantation. The failure rate of this procedure is high in this location. Thus, autologous chondrocyte implantation of the knee is not likely to be more efficacious than other treatment options. 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: Experimental
Decision: Upheld

Summary Reviewer 3


A 62-year-old male has requested authorization and coverage for cervical total disc arthroplasty.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees neck pain and radiculopathy of arm. The physician reviewer found this patient has a history of anterior cervical discectomy and fusion at C5-C6 and adjacent segment disease at C4-C5 with a large herniation.  There is evidence of a right C5 radiculopathy.  Conservative treatment has been tried and failed.  A review of the recent literature reveals that artificial disc replacement is superior to anterior cervical discectomy and fusion in that it will allow motion.  The requested procedure can maintain the range of motion of the replaced segment as well as the adjacent unfused segment. Based on this analysis, fusion plus disc replacement procedure has less severe biomechanical effects on adjacent levels when compared to bi-level fusion procedure.  Thus, the cervical total disc arthroplasty is likely to be of greater benefit than other treatment options.  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 2

A 33-year-old male enrollee has requested reimbursement for Prometheus Anser ADA diagnostic testing performed on 5/19/14.  The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the Prometheus Anser ADA test is a quantitative measurement of serum adalimumab and anti-ADA antibodies. Some evidence exists that low serum levels of ADA or the presence of ADA antibodies have an adverse effect on the clinical outcome of a patients response to treatment. There are few well controlled clinical trials to confirm that use of the Anser ADA test leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al). Moreover, in patients with IBD who lose response to ADA, clinical improvement may occur upon intensification of ADA therapy, irrespective of ADA serum concentration or presence of anti-ADA antibodies (Steenholdt, et al). As such, the clinical utility of measuring drug antibody concentrations is on a case-by-case basis. Based on the clinical documentation submitted for review, it has not been established how this patients specific management would change based on test results. In addition, there are technical factors relating to the use of different assay methods across studies. It has not yet been established whether the use of threshold levels aids in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established, such as in this case. For the reasons provided, the Prometheus Anser ADA diagnostic testing performed on 5/19/14 was not more beneficial for treatment of the patients medical condition than conventional treatment strategies. 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

The parent of a 14-year-old male enrollee has requested reimbursement for wilderness treatment therapy provided from 7/16/18 through 8/30/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. In this case, the appropriate level of care must be determined before the suitability of wilderness treatment can be assessed. With regard to risk of harm, the records support a score of 3. The documentation noted impulsive behaviors and outbursts, as well as the risk of victimization by peers. No episodes of physical aggression are reported in the six months prior to enrollment in the wilderness program. In terms of functional status, the records support a score of 3. The records noted moderate functional impairment, due to conflict with family members and problematic interactions with peers. With regard to comorbidity, the records support a score of 2, due to the combination of mental illness and possible mild neurodevelopmental disorder. In terms of level of stress of the recovery environment, the records support a score of 2. The environment was mildly stressful, due to recent change in school. With regard to environmental support, the records support a score of 1. The environment was highly supportive due to his parents involvement in treatment, ability to provide resources, and efforts to provide support for patient. In terms of resiliency and treatment history, the records support a score of 3. The records document deterioration in functioning after transitioning to middle school, and lack of remorse for his actions. With regard to acceptance and engagement, the records support a score of 3. The patient was incompletely engaged, due to his failure to accept responsibility for his actions. Thus, the patient has a total score of 17. Therefore, the appropriate level of care was high-intensity community-based services. In sum, wilderness treatment therapy provided from 7/16/18 through 8/30/18 was not likely to have been more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a 17-year-old male enrollee has requested reimbursement for the mental health inpatient services provided from 5/31/18 through 6/6/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found that according to the American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII), the mental health inpatient services provided from 5/31/18 through 6/6/18 were medically necessary. Per the documentation dated 5/31/18, the patient remained symptomatic. He was noted to be isolative and functioning below the level of his peers. He continued to endorse grandiose delusions, had disorganized thought process, as well as poor insight and judgment. Based on the documented history and clinical status, the patient met CASII service intensity criteria for secure 24-hour service with psychiatric management for the dates of service at issue. Moreover, the current medical literature supports that the continued services were medically necessary (Gray and Squeglia; Starzer, et al). Therefore, the mental health inpatient services provided from 5/31/18 through 6/6/18 were medically necessary for treatment of this patients behavioral health issues. Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1 
 
A 69-year-old female enrollee has requested reimbursement for Guardant 360 testing 
performed on 1/11/21. 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 integration of plasma next generation sequencing (NGS) 
testing into the routine management of stage IV non-small cell lung cancer demonstrates a 
marked increase of the detection of therapeutically targetable mutations and improved 
delivery of molecularly guided therapy. This is recommended by the National Comprehensive 
Cancer Network (NCCN) if there is insufficient tissue for NGS from tumor. Per the NCCN, The 
use of cell-free/circulating tumor DNA testing can be considered in specific clinical 
circumstances, most notably: if a patient is medically unfit for invasive tissue sampling; in the 
initial diagnostic setting, if following pathologic confirmation of a non-small cell lung cancer 
diagnosis there is insufficient material for molecular analysis, cell-free/circulating tumor DNA 
should be used only if follow-up tissue-based analysis is planned for all patients in which an 
oncogenic driver is not identified; in the initial diagnostic setting, if tissue-based testing does 
not completely assess all recommended biomarkers owing to tissue quantity or testing 
methodologies available, consider repeat biopsy and/or cell-free circulating tumor DNA 
testing. In this patients case, the Guardant 360 requisition noted that tissue-based 
comprehensive genomic profiling from a recent biopsy was not feasible. Thus, there is sufficient 
support for the services at issue in this clinical setting. Therefore, Guardant 360 testing 
performed on 1/11/21 was likely to have been more beneficial than other methods of 
evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 61-year-old female who presented to her provider on 5/25/21 with a complaint of worsening knee pain. The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left knee. The physician reviewer found that the current medical evidence does not support the requested services in this clinical setting. The incidence of abnormal MRI findings in asymptomatic individuals was established as early as 1992 by Boden and colleagues. The authors noted, aThe high incidence of abnormal MRI findings in asymptomatic subjects underscores the danger of relying on a diagnostic test without careful correlation with clinical signs and symptoms.a In other words, simply obtaining an MRI without correlation with a detailed clinical examination can lead to unnecessary conclusions, and even worse, unnecessary surgery.  For this reason, conservative management, as suggested by the Health Insurer, is certainly worthwhile. In the requisition for the knee MRI, it is stated that the patient has had four weeks of prior physical therapy as well as supervised home exercise program within the prior three months. However, the records do not document this. The submitted documentation does not demonstrate that the patient has completed an appropriate course of conservative management. The records do not document that the patient actually underwent physical therapy. Absent this documentation, the medical necessity of the requested services cannot be established. Therefore, the requested MRI of the left knee is not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 61-year-old male enrollee has requested authorization and coverage for positron emission tomography (PET) scan. The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the patient has a rapidly rising prostate-specific antigen level after radical prostatectomy, and there were inconsistencies on imaging.  It has been extensively shown that sodium fluoride positron emission tomography/computed tomography (PET/CT) is a sensitive means with which to detect boney metastases, and this modality would provide the best assessment for the extent of metastatic disease.  As the most sensitive bone scanning agent available, this requested technique would be the best way to analyze the equivocal findings.  In sum, the requested PET scan is likely to be superior over other methods of evaluating this patient.  Based upon the information set forth above, the requested services are 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

The parent of a 12-year-old male enrollee has requested authorization and coverage for Remicade 400 mg for two weeks and then once monthly for one year. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees juvenile dermatomyositis (JDMS). The physician reviewer found in this case, the patients current treatment consists of two oral disease modifying agents, CellCept and methotrexate for a diagnosis of juvenile dermatomyositis. The documentation submitted for review fails to provide supporting evidence of active disease at this time. There is a lack of evidence demonstrating active vasculitis or active inflammatory muscle disease. On the basis of this lack of documentation, escalation of therapy with an additional agent is not warranted and Remicade is not clinically indicated. As such, the request for Remicade is not likely to be more beneficial than other modalities. 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: Experimental
Decision: Overturned

Summary Reviewer 1 
 
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 the National Comprehensive Cancer Network (NCCN) guidelines for the treatment of 
non-small cell lung cancer (NSCLC) note that there is growing recognition of the molecular 
mechanisms of resistance to therapy. Retesting a sample from a tumor that is actively progressing 
while exposed to targeted therapy can shed light on appropriate next therapeutic steps. Broad 
genomic profiling may be the most informative approach to examining potential mechanisms of 
resistance, which may require more than one instance of such profiling over the course of an 
individual patients therapy. While liquid biopsy should not be used in lieu of tissue-based testing, 
Rolfo  and  colleagues  note  that  isolation  and  analysis  of  circulating  cell-free  tumor 
deoxyribonucleic acid (DNA) in plasma is a powerful tool with considerable potential to improve 
clinical outcomes across multiple cancer types, including NSCLC. Cell-free tumor DNA testing 
generally has very high specificity. While it may also have significantly compromised sensitivity, 
with up to a 30% false-negative rate, current medical literature supports complementary testing to 
reduce turnaround time and increase the yield of targetable alteration detection. This is especially 
true with procedures that typically have a low yield of tissue such as endobronchial ultrasound 
(EBUS). Therefore, the service at issue was likely to have been more beneficial for treatment of 
the patients medical condition than standard therapy with tissue-based testing alone. Therefore, 
CDx laboratory testing by FoundationOne on 4/29/22 was likely to have been more beneficial for 
evaluation of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 64-year-old male enrollee has requested authorization and coverage for Privigen. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. Patients with myasthenia gravis can have weakness of the ocular, limb, respiratory, and bulbar muscles. The nature of the pathogenesis and the anatomical target can create clinical situations that are very diverse. The clinical presentation can range from mild symptomatology with mild weakness or cosmetic changes to severe life-threatening clinical scenarios involving difficulty with breathing, ambulating, eating, and speaking. The treatment of myasthenia gravis is dependent on several factors, including the patients medical comorbidity, age, involvement of respiratory or bulbar muscles, progression and severity. IVIG is considered a safe and effective tool in the maintenance and acute management of myasthenia gravis. Therefore, Privigen is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 59-year-old female enrollee has requested reimbursement for the computed tomography (CT) scan performed on 11/17/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for evaluation of the enrollees risk of coronary artery disease. The physician reviewer found that based on the records provided for review, the patient is a 59-year-old female with increased coronary risk but no documented symptoms or objective findings concerning for coronary ischemia. In this circumstance guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including screening coronary CT scanning. Treatment change or addition based on the results of screening with coronary CT scanning has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Therefore, the CT scan performed on 11/17/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Based upon the information set forth above, the diagnostic procedure 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 50-year-old female enrollee has requested reimbursement for inpatient admission from 9/21/15 through 9/22/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patients symptoms had resolved prior to admission.  Her vital signs were stable at the time of admission, and the physical examination did not show signs of congestive heart failure or arrhythmia. The initial troponin level was normal. In addition, the provider documentation did not include any reasoning for assignment of the inpatient status. The treatment ordered did not include intravenous nitroglycerin or acute anticoagulation. Urgent cardiac catheterization was not recommended or performed. All of the ordered services were of the intensity that could have been safely provided at the observation level. Had any complication or problem occurred, or the subsequent testing indicated myocardial ischemia, the patient could have appropriately been converted to inpatient status at that time.  All told, inpatient admission from 9/21/15 through 9/22/15 was not medically indicated for the treatment of this patient.  Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.