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

Summary Reviewer 2

A 56-year-old female has requested reimbursement for percutaneous tibial nerve stimulation performed from 5/08/18 through 8/02/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of urinary frequency and urgency. The physician reviewer found that there is evidence in the peer-reviewed literature from randomized trials and prospective observational trials supporting the clinical utility and impact on patient management of percutaneous tibial nerve stimulation in patients with urinary urgency and frequency. However, most trials have a small number of patients with short-term follow-up. American Urological Association (AUA) guidelines recommend that clinicians should offer behavioral therapies, such as bladder training, bladder control strategies, pelvic floor muscle training and fluid management, as first-line therapy to all patients with overactive bladder. Behavioral therapies may be combined with pharmacologic management. Clinicians should offer oral antimuscarinics or oral 3-adrenoceptor agonists as second-line therapy. If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti-muscarinic medication, then a dose modification or a different anti-muscarinic medication or a 3-adrenoceptor agonist may be tried. Patients who are refractory to behavioral and pharmacologic therapy should be evaluated by an appropriate specialist if they desire additional therapy. The guidelines rate percutaneous tibial nerve stimulation as a third-line therapy. Botox injection is a standard third-line therapy which is graded better. The use of percutaneous tibial nerve stimulation has not been proven to be superior to other alternatives. In this case, the records do not document that the patient had a complete trial and failure of first-line and second-line therapy. The documentation does not support prior failure of behavior modification. She was prescribed low dose Toviaz, the response to which is unknown. The first intervention would be dose escalation if she had no response to low dose Toviaz. In sum, percutaneous tibial nerve stimulation performed from 5/08/18 through 8/02/18 was not likely to have been superior over other treatment options. 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 26-year-old male enrollee has requested reimbursement for cervical discography injection provided on 6/25/20. The Health Insurer indicates that the services at issue were investigational for the treatment of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue.  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. Additional records were reviewed, and these records fail to demonstrate the superior efficacy of the services at issue. Manchikanti and colleagues concluded that lumbar provocation discography performed according to the International Association for the Study of Pain (IASP) criteria may be a useful tool for evaluating chronic lumbar discogenic pain. The evidence is weaker for cervical and nonexistent for thoracic discography. In this case, the patient has been treated for cervical pain. There is a history of cervical spine fusion in March 2019. The patient developed worsening neck pain for which he has undergone extensive conservative pain management, with no clinical response. He demonstrated high cervical mechanical pain characteristics unassociated with any significant referral or radiation. Examination revealed no high cervical facet clinical provocation by deep palpation. He is neurologically intact. However, there are limited large-scale, long-term references showing the safety and efficacy of this modality. There were no extenuating circumstances in this patients clinical data to support otherwise. Therefore, cervical discography injection provided on 6/25/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 55-year-old female enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine. The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees neck pain. The physician reviewer found the submitted records support the medical necessity of the requested services. This patient has had symptoms for a prolonged period of time, with no apparent relief, and now has been referred for additional cross-sectional imaging as well as to an orthopedist for consultation.  For the first study for patients with chronic neck pain with or without a history of previous trauma, the American College of Radiology does not recommend computed tomography (CT) and states that an MRI is usually not appropriate.  However, the American College of Radiology considers MRI to be the appropriate next imaging modality for patients with radiographs which show degenerative changes when neurologic signs or symptoms present.  In this case, the patient has numbness and tingling extending to her fourth and fifth fingers.  Her symptoms are more than just neck pain.  The localization of symptoms to her fourth and fifth fingers are typical for a C8 dermatome.  In this setting, MRI of the cervical spine is considered the most appropriate next imaging modality. This patient has already had a trial of anti-inflammatory medications.  All told, the requested MRI of the cervical spine is medically necessary for the evaluation of this patient. Therefore, the requested services are medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 52-year-old male enrollee has requested authorization and coverage for implant stimulator.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees complex regional pain syndrome to his right foot. The physician reviewer found that there is some support for the requested services in this patients case. The patient has severe CRPS of the right foot and has been non-responsive to a variety of interventional options including intrathecal pump and traditional spinal cord stimulation stimulator. The patients pain pattern is amenable to DRG stimulation along the lower lumbar nerve roots. DRG stimulation is proven to have long-term benefit for CRPS when other modalities have failed and is likely to be more effective than any other available standard therapy for the treatment of this patients medical condition. Therefore, for the reasons stated 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 3

A 54-year-old female has requested reimbursement for chemotherapy treatment provided from 10/06/17 through 12/13/17. The Health Insurer has denied this request indicating that the medication regimen at issue was considered investigational for treatment of the enrollees gallbladder cancer. The physician reviewer found that there is support for the medication regimen at issue in this clinical setting. In this case, the tumor was advanced at stage IVA. Most clinical phase II clinical trials of chemotherapy regimens in cholangiocarcinoma are small since the disease is rare. There is good evidence for the initial regimen utilized here, gemcitabine/oxaliplatin, but with progression and an Eastern Cooperative Oncology Group (ECOG) performance status of 1, a second-line regimen was appropriate. FOLFIRI is a common chemotherapy regimen effectively applied in colorectal cancer but has been extended to pancreatic and gallbladder patients. FOLFIRI/bevacizumab has been examined as second-line treatment in metastatic cholangiocarcinoma patients. The addition of bevacizumab is supported by additional independent clinical data. The FOLFIRI/bevacizumab combination is safe and effective and was medically appropriate in this patient with limited treatment options. Thus, chemotherapy treatment provided from 10/06/17 through 12/13/17 was likely to have been of greater benefit than other available treatment options. Based upon the information set forth above, the medication regimen at issue was 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: Overturned

Summary Reviewer 2


A 62-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 3/31/16.  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 This patient is a 62-year-old female who had a bilateral screening mammogram with tomosynthesis on 3/31/16. The patient reported a positive family history of breast cancer in her maternal grandmother, and in her maternal and paternal aunts. The patient presented for a breast screening examination on 3/31/16. The patients breast was noted with scattered fibroglandular densities in the right breast. The ultrasound showed small cysts. The Health Insurer has denied the tomosynthesis portion of the exam. The patient has appealed the denial and this denial is the subject of this appeal and determination.
The medical literature supports breast tomosynthesis in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus the literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis performed on 3/31/16 was likely to have been superior to other methods of evaluating this patient. 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 42-year-old male enrollee has requested authorization and coverage for Tremfya. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that the American Academy of Dermatology guidelines for the management of psoriasis recommend topical therapy as first-line treatment. If ultraviolet therapy is not available, other first-line treatments include: acitretin, adalimumab, cyclosporine, etanercept, infliximab, methotrexate and ustekinumab. In this case, the patient has failed prior therapy with topical medications, narrowband ultraviolet B therapy, methotrexate, Cosentyx, Taltz, Stelara, and Enbrel. He was unable to tolerate Remicade. In a letter dated 1/14/19, the provider stated that the patient requires dual therapy with Otezla and Tremfya to achieve satisfactory control of his psoriasis. However, the combination of Otezla and Tremfya has not been widely accepted as the standard of care in the management of refractory psoriasis. It is not yet known if the combination of Otezla and Tremfya would be safe for long-term use. In sum, Tremfya is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 27-year-old male enrollee has requested reimbursement for vitamin D testing performed on 1/15/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the clinical manifestations of vitamin D deficiency depend upon the severity and duration of the deficiency. The majority of patients with moderate to mild vitamin D deficiency are asymptomatic. With severe vitamin D deficiency, there can be hypocalcemia, which leads to bone disorders.   Patient groups who are at risk for vitamin D insufficiency includes patients who are obese, those taking medications that accelerate the metabolism of vitamin D, hospitalized or institutionalized patients or individuals who have limited effective sun exposure. Other people at high risk include those with osteoporosis or malabsorption, including inflammatory bowel disease and celiac disease. Screening of the general population is not recommended. Normal-risk adults do not need assessment. In this case, the patient did not have any chronic medical conditions that would cause vitamin D deficiency. Therefore, vitamin D testing performed on 1/15/20 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 65-year-old female enrollee has requested reimbursement for collagen crosslink testing and homocysteine testing provided on 12/03/18. 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 there is a lack of support for the services at issue in this clinical setting. If the patient has received therapy, it would be appropriate to have a dual-energy x-ray absorptiometry (DEXA) at the end of the two-year treatment to assess the response to therapy. The value of monitoring therapy with the use of biochemical markers of bone turnover to aid in clinical decision is controversial. It is a test that can be variable and subject to timing, dietary intake as well as lack of assay standardization. Thus, collagen crosslink testing and homocysteine testing provided on 12/03/18 were not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 58-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 1/03/17 and transfer of the laboratory specimen. 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 DecisionDx-Melanoma testing is a 31-gene expression profile used to determine the risk of recurrence of melanomas. Per the National Comprehensive Cancer Network guidelines, routine (baseline) prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. At this time, the medical evidence has not established that the results of such genetic profiles has an independent prognostic value. The standard of care for the patient would have been wide excision and consideration of sentinel lymph node sampling, and additional follow-up could be determined by those results.  All told, DecisionDx-Melanoma testing performed on 1/03/17 and transfer of the laboratory specimen was not likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 63-year-old female has requested reimbursement for Anser ADA testing provided on 4/25/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found the concept of therapeutic drug monitoring of biologics in this clinical setting is not evidence-based.  There is no target drug level threshold which has been established.  Often, patients with a low or undetectable trough drug level are in clinical remission. Additionally, although antibodies are associated with lower drug levels and drug failure, in many patients, antibodies are transient and not of clinical significance.  In sum, Anser ADA testing performed on 4/25/16 was not 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 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

The patient is a 43-year-old female with right sided low back and sacroiliac pain that has failed conservative treatment. The provider has recommended a minimally invasive sacroiliac fusion using the I-Fuse implant. A review of her medical record indicates a history of chronic right sided low back and buttock pain that does not radiate down the leg. She received excellent relief from the first right sacroiliac joint injection. The magnetic resonance imaging (MRI) scan does show degenerative disc disease at L5-S1 but there is no neuro-compressive lesion. There is no clinical evidence of radiculopathy. The provider has documented failed conservative treatment including physical therapy and medications. The patient has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request on the basis that the requested services are investigational for the treatment of this patient. The medical evidence show that sacroiliac joint degeneration is a common cause of chronic low back pain, which is under diagnosed.  Minimally invasive fusion procedures have demonstrated successful pain relief.  Among these implants, the triangular titanium implants such as I-fuse have been used. Recent medical literature has documented two year follow up of these procedures demonstrating meaningful clinical improvement and maintained pain relief as well as evidence of a solid fusion on imaging studies. Cross and colleagues performed a study of patients with sacroiliac joint dysfunction who were treated with minimally invasive sacroiliac joint fusion using triangular titanium implants. The results from their study showed marked improvements in pain, disability and quality of life at two years. Imaging showed that bone apposition to implants was common but radiographic evidence of intraarticular fusion within the joint may take more than one year in many patients. This case illustrates the difficulty encountered in making an accurate diagnosis of chronic low back pain that does not respond to conservative measures.  In the absence of evidence of neural compression on the MRI scan and in the presence of clinical findings of sacroiliac pain, which is relieved by injecting the sacroiliac joint, the requested procedure using the minimally invasive technique is likely to be successful in this individual.  Accordingly, the request for a sacroiliac joint fusion is likely to be more effective in treating this patients low back pain than the available standard techniques. Therefore, based upon the information set forth above, the requested procedure is 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: Overturned

Summary Reviewer 1
A 50-year-old female enrollee has requested reimbursement for breast tomosynthesis imaging performed on 2/10/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee who presented for her annual breast examination. The physician reviewer found that there is evidence-based support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two dimensional protocol on 2/10/17 was likely to have been more effective than had her examination been performed using two dimensional imaging alone. Based upon the information set forth above, the service at issue was likely to be more beneficial for the 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 63-year-old female enrollee has requested reimbursement for an Anser ADA test performed on 5/12/15. The Health Insurer has denied this request indicating that the procedure at issue was considered investigational for evaluation of the enrollees Crohns disease with ileostomy. The physician reviewer found that for this clinical setting, the Anser ADA test was likely to be more beneficial than any available standard therapy in management and treatment of the patients medical condition. The patient had been on Humira after she had failed multiple prior regimens. There could have been multiple reasons for this, each of which has a different path of management. The Anser ADA test measures the Humira blood level and detects antibodies to Humira.  Patients with detectable levels and no antibodies will have to have a change in treatment management in order to control their disease, as the test implies an escape phenomenon to Humira. Patients with undetectable levels and antibodies are under-dosed and a higher dose will be needed to achieve remission and control of disease.  Patients with a low level and detectable antibodies have a low drug level due to the development of antibodies. Hence, due to the multitude of management options, once a patient loses response to the biologic or has unexplained episodic symptoms that could be attributed to disease flares (such as this patient), the Anser ADA test is an effective tool for the treating provider in the management of their patients medical condition. For these reasons, the Anser ADA test performed on 5/12/15 was like to be more beneficial for evaluation of this patients medical condition than any available standard modality. In sum, the procedure 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.