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

Summary Reviewer 3


A 55-year-old male enrollee has requested reimbursement for the prostate cancer antigen 3 (PCA3) gene testing performed on 1/30/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the PCA3 testing was likely to be more effective for this patient than other available treatment options. PCA3 is expressed by most prostate cancers and has been analyzed as a screening test in clinical trials with sensitivities and specificities. PCA3 is appropriately used to recommend biopsy in those patients with indeterminate PSA levels or in those with initial negative prostate biopsies (Marks, et al; Deras, et al). In this case, the test was appropriately used to decide upon biopsy and the medical evidence supports it use in this clinical setting. In sum, the PCA3 testing 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 61-year-old male with a medical history including diabetes mellitus who presented to the emergency department after a bicycle versus car collision, resulting in multiple injuries. His injuries included a non-displaced clavicular fracture, left-sided rib fractures at ribs 4 and 6, a small pneumothorax and a pelvic fracture. The physician reviewer found that at the time of admission, the patient was hemodynamically stable without hypoxia. His pain was controlled. He did not suffer from any open traumatic fractures or head injury. There were no urgent procedures or surgeries required. The laboratory studies were mostly unremarkable, except for a mildly elevated glucose level. The inpatient admission was not medically necessary for this
patient. Inpatient care is necessary when the patientas signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition with improved symptoms and could have been treated at a lower level of care, like observation. He remained stable and did not have any complications that would require inpatient admission. Therefore, inpatient services provided from 10/12/20 through 10/13/20 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 59-year-old male who presented with hematochezia in August 2021. The patient 
has requested authorization and coverage for PET imaging with concurrent CT skull base to mid-
thigh. The physician reviewer found that there is sufficient support for the requested services in 
this clinical setting. According to the National Comprehensive Cancer Network (NCCN) guidelines, 
PET/CT has a limited sensitivity but high specificity, and may be considered when there is an 
equivocal finding. When hepatocellular carcinoma is detected by CT or magnetic resonance 
imaging (MRI) and has increased metabolic activity on PET/CT, higher intralesional standardized 
uptake value (SUV) is a marker of biologic aggressiveness and might predict less optimal response 
to  locoregional  therapies.  Sensitivity  is  a  metric  for  the  screening  of  cancer,  but  for 
discriminating responses, the specificity may be most relevant.  The original disease showed 
significant FDG uptake. There were multiple sites of disease making the interpretation of follow-
up imaging very complex. The use PET/CT is medically necessary for further care. Therefore, the 
requested PET imaging with concurrent CT skull base to mid-thigh is medically necessary for the 
evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 39-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea. The physician reviewer found that obstructive sleep apnea is an increasingly prevalent clinical problem with significant effects on both personal and public health. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. Hypoglossal nerve stimulator has been found to be safe and effective in a small subset of patients with obstructive sleep apnea who have failed CPAP, have nonconcentric airway collapse, an AHI between 20 and 50, and a body mass index (BMI) less than 32. With a BMI of 31.1, AHI of 53.3 and nonconcentric airway collapse, this patient meets the criteria. He has failed CPAP, which is the gold standard treatment for obstructive sleep apnea. Therefore, hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System 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 25-year-old female has requested authorization and coverage for intravenous ceftriaxone.  The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found the medical evidence does not support the requested medication in this patients case.  The patients symptoms are non-specific, and the examination findings are non-focal.  The laboratory examination was negative for Borrelia infection.  The diagnosis of late stage neuroborreliosis or Lyme arthritis has not been established.  If the diagnosis of neuroborreliosis was established, the standard of care is one four-week course of intravenous ceftriaxone.  Repeat or longer term courses of antibiotic have not been shown to be efficacious. The peer-reviewed literature does not demonstrate evidence for the requested medication in this clinical setting. All told, the requested intravenous ceftriaxone is not likely to be superior over other methods of treating this patient.  Based upon the information set forth above, the requested medication is 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 

The patient is a 36year-old female with a history of low back and right lower extremity pain due to a disc herniation at L4-5.  The patient has requested reimbursement for anterior interbody fusion with cage lumbar disc L4-5 performed on 4/23/21 and two days of inpatient hospitalization. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Phan and colleagues performed a meta-analysis of seven studies, including 181 patients who underwent anterior lumbar discectomy and fusion after primary discectomy had resulted in a recurrence of low back and leg pain, as in this patients case. The authors noted that there are certain advantages to the anterior approach. Repeat posterior approach for recurrent herniations may result in trauma to the spinal nerves and paraspinal muscles that is avoided in the anterior approach. Furthermore, the authors noted that the exposure allows for a comprehensive discectomy. In these 181 patients, there was significant improvement in the Oswestry Disability Index and Visual Analogue Scale (VAS) back and leg pain scores. The average length of hospital stay was 5.28 days. This patient has requested reimbursement for the surgery and two days of inpatient hospitalization. The authors concluded that anterior lumbar interbody fusion is a feasible approach for the treatment of recurrent lumbar disc herniations and demonstrates good results, with minimal complications. As such, in the presence of a recurrent herniation with chronic low back and leg pain, and failure of conservative treatment, the services at issue were medically indicated. Therefore, the anterior interbody fusion with cage lumbar disc L4-5 performed on 4/23/21 and two days of inpatient hospitalization were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 45-year-old female enrollee has requested reimbursement for FoundationOne CDx testing performed on 1/29/19. 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 molecular basis of neuroendocrine tumors remains poorly understood, and additional molecular predictors of outcome remain investigational. Per the National Comprehensive Cancer Network guidelines, more research is required before new molecular assays are routinely used in the clinic. A multinational consensus meeting of experts concluded that, to date, no single currently available biomarker is sufficient as a diagnostic, prognostic, or predictive marker in patients with neuroendocrine tumors. There are still treatment options available. Thus, FoundationOne CDx testing performed on 1/29/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 27-year-old female enrollee has requested reimbursement for inpatient level of care provided on 5/20/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient presented with symptoms consistent with urinary tract infection. At the time of admission, she was afebrile and hemodynamically stable. She did not have significant pain at the time of admission. She was tolerating oral hydration and could be treated with oral antibiotics.  There was no evidence of urinary tract obstruction. The inpatient admission was not medically necessary for this patient. She could have been treated at a lower level of care. Therefore, inpatient level of care provided on 5/20/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 54-year-old female enrollee has requested reimbursement for left and right eye refraction surgery performed on 9/19/16 and 10/07/16. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollee, who has a history of blurred vision. The physician reviewer found that the submitted submitted documentation supports the medical necessity of a portion of the services at issue. The records show that the patient did have symptomatic cataracts requiring surgery. The Health Insurers argument that the surgery was purely for refractive reasons was not substantiated upon reviewing the medical records. Thus, the portion of surgeries to treat cataract was medically necessary. The additional treatments of femtosecond laser and multifocal intraocular lens were for the purpose of refractive treatment and were not medically necessary. Therefore, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 61-year-old female 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 lung cancer. The physician reviewer found that of the original indications for PET scan was the evaluation of solitary pulmonary nodules to determine the likelihood of malignancy based on high standardized uptake values (SUV). Primary lung cancer greater than 1 cm in diameter has a very high true positive rate on PET/CT versus other post therapy and infectious etiologies. In this patient with a question of recurrent lung cancer versus scar formation and the contraindication of biopsy of the lesion due to severe COPD, PET scan is likely to be more beneficial than 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: Upheld

Summary Reviewer 1

The parent of a 10-month-old female enrollee has requested authorization and coverage for lansoprazole. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that the clinical practice guidelines adopted by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition support the use of proton pump inhibitors in infants with severe gastroesophageal reflux disease if a trial of hydrolyzed formula has failed. The use of proton pump inhibitors in infants with severe gastroesophageal reflux disease is consistent with the standard of care. The safety and efficacy of this class of medications are well-established and supported by sufficient scientific evidence. This patient has already failed to respond to hydrolyzed formula and to acid suppression with H2 blockers. A trial of a proton pump inhibitor is the most appropriate next step in the management of this patient. Therefore, lansoprazole is likely to be more efficacious than other treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 52-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene expression testing performed on 11/01/18. 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 this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines states that 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. There is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. In sum, DecisionDx-Melanoma gene expression testing performed on 11/01/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 50-year-old male enrollee has requested reimbursement for BCR/ABL gene rearrangement and the Tempus XT Gene Panel Testing performed on 12/17/18. 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 this patient has a grade I meningioma. Magnetic resonance imaging (MRI) showed a question of slow growth versus tumor progression. There is no rationale for molecular profiling or BCR-ABL testing in this patient. Molecular profiling is used to determine treatment options in certain malignancies, but not grade I meningiomas. BCR-ABL is used in the detection and monitoring of chronic myelogenous leukemia, acute myeloid leukemia and acute lymphoblastic leukemia. In rare cases, BCR-ABL1 has been described in essential thrombocytosis, myelodysplastic syndrome, multiple myeloma (plasma cell myeloma), and malignant lymphoma. Therefore, BCR-ABL gene rearrangement and the Tempus XT Gene Panel Testing performed on 12/17/18 were not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 51-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 4/15/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found by monitoring patients on infliximab with measurement of infliximab levels and antibodies to infliximab continues to be an area of intense investigation.  In general, infliximab levels correlate inversely with disease activity.  However, the target level of infliximab necessary to achieve clinical benefit remains unknown.  There is a lack of support for the services at issue in this clinical setting.  Many patients lose response to a tumor necrosis factor (TNF) alpha inhibitor for unclear reasons.  All told, Anser IFX testing performed on 4/15/14 was not likely to have been of greater benefit than other methods of evaluation.  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: Overturned

Summary Reviewer 

A 65-year-old female enrollee has requested reimbursement for inpatient admission from 12/06/17 through 12/07/17. 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 the patient presented with anginal type symptoms after a stressor. Although she did not have fixed coronary artery disease, she met all the criteria for Takasubos stress cardiomyopathy with T wave inversions, positive low-level troponin elevations and an echocardiogram, which revealed severe apical hypokinesis with depressed ejection fraction. Although not often associated with fixed coronary artery disease, the prognosis for stress cardiomyopathy is also very guarded, and recent data and meta-analyses reveal that there is significant short and long-term morbidity and mortality associated with this entity.  Therefore, monitoring for rhythm disturbances, hypotension and other complications of myocardial infarction is warranted with an inpatient admission, even if short. Troponins, electrocardiogram and echocardiogram all showed evidence of acute myocardial damage in this patient. Therefore, inpatient admission from 12/06/17 through 12/07/17 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 62-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 7/25/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. The physician reviewer found that the therapy of advanced non-small cell lung cancer (NSCLC) has been revolutionized by the finding of EGFR mutations in adenocarcinomas. Even if stage IV disease is present, therapy targeted to EGFR with erlotinib results in prolonged survival when compared with standard chemotherapy regimen. The mutational landscape of NSCLC has significantly expanded to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. Thus, mutational analysis on its own is clinically indicated in these cases of NSCLC. Plasma cell free/circulating tumor DNA testing is indicated if the primary tumor is inaccessible. According to the National Comprehensive Cancer Network guidelines, In the initial diagnostic setting, if following pathologic confirmation of NSCLC 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 this case, insufficient material was available after the biopsy. The medical evidence supports the services at issue in this patients case. Therefore, Guardant360 testing performed on 7/25/20 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

The patient is a 62-year-old male with a progressive group of symptoms consistent with a neurodegenerative disorder.  He has developed dysarthria, ataxia and possibly cognitive abnormalities of executive functioning. Per the records, magnetic resonance imaging (MRI) of the brain showed atrophy of the cerebellum, cerebellar peduncles, and pons and medulla consistent with multisystem atrophy or possibly spinocerebellar degeneration. The provider recommended dopamine transporter single photon emission computed tomography (DaT SPECT). The patient has requested reimbursement for DaT SPECT scan of the brain performed on 9/23/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  There is a lack of support for the services at issue in this clinical setting.  The differential diagnosis of spinocerebellar degeneration versus multiple system atrophy is established by clinical grounds. There is a lack of data demonstrating adequate sensitivity or specificity of DaT SPECT scanning in this clinical setting.  Therefore, DaT SPECT scan of the brain performed on 9/23/16 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.