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

Summary Reviewer  
 
The patient is a 40-year-old female who presented with an abnormal mammogram. The patient 
has requested authorization and coverage for proton beam radiation therapy. The physician 
reviewer found that guidelines do not endorse the routine use of proton beam radiation therapy 
in the treatment of breast cancer. There is a lack of data to suggest that proton beam radiation 
therapy would be beneficial in this case or that it would be associated with less side effects than 
standard  treatment  with  three-dimensional  conformal  or  standard  intensity  modulated 
techniques which are typically given with partial breast radiation. Furthermore, consensus group 
guidelines do not support the use of proton beam radiation therapy in this setting. Typically, 
photon treatments using deep inspiratory breath hold which moves the heart away from the 
chest wall are associated with very low cardiac doses in patients receiving radiation to the left 
chest wall. The comparative planning does not support the use of proton beam radiation therapy, 
as typically treatment with deep inspiratory breath hold using photons is associated with a mean 
heart dose of less than 4 Gy.  Additionally, there is a lack of level I evidence to support the use of 
proton beam radiation therapy for the treatment of breast cancer. Therefore, the requested 
proton beam radiation therapy is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 43-year-old female enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain.   The physician reviewer found this patient meets the criteria for a minimally invasive SI fusion. In the peer-reviewed medical literature, Polly and colleagues reported on a randomized controlled trial of 148 patients treated with minimally invasive SI joint fusion using triangular titanium implants or nonsurgical treatment with follow-up at one year. The authors concluded that this level one study showed that minimally invasive SI joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with sacroiliac joint dysfunction caused by degenerative sacroiliitis or SI joint disruptions. In another recent study, Whang and colleagues found that six month follow-up from this level one study showed that minimally invasive SI joint fusion using triangular titanium implants was more effective than nonsurgical management in relieving pain, improving function, and improving quality of life in patients with SI joint dysfunction due to degenerative sacroiliitis or SI joint disruptions. Based upon a review of the recent literature, the requested minimally invasive form of SI joint fusion is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 52-year-old male enrollee has requested reimbursement and prospective authorization and coverage for elotuzumab (Empliciti) from 1/4/17 through 7/3/17. The Health Insurer has denied this request indicating that the medication at issue was and is considered investigational for treatment of the enrollees myeloma. The physician reviewer found that there is no dispute that pomalidomide with Empliciti and Decadron is not a compendia or literature supported regimen. As the patient has responded to Empliciti with pomalidomide and Decadron, per the National Comprehensive Cancer Network (NCCN) compendium, the continued use of Empliciti in combination with the proposed clinical trial was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the medication at issue was and 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: Upheld

Summary Reviewer 2


A 48-year-old female enrollee has requested authorization and coverage for a Cochlear Baha Attract System.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that The Cochlear Baha Attract System is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The study by Gawecki and colleagues evaluated surgical, functional and audiological results of the Baha Attract System. The authors concluded that the data obtained prove the safety and effectiveness of the Baha Attract system in patients with conductive and mixed hearing loss as well as in patients with single-sided deafness. Cosmetic aspects are highly acceptable and the idea of Attract itself is important for patients with limited manual dexterity. In addition, the Cochlear Baha Attract System is U.S. Food and Drug Administration approved device for the treatment of unilateral deafness. In this case, the patient is suffering from unilateral profound hearing loss with normal hearing in the other ear. As such, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 67-year-old male enrollee has requested reimbursement for gene testing performed on 4/19/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees metastatic renal cell carcinoma. The physician reviewer found that FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers that can help guide therapy decision making. Per the National Comprehensive Cancer Network guidelines, it has not been determined if molecular markers are useful in treatment determination (predictive markers) and prognosis. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. At this time, the superior efficacy of gene testing performed on 4/19/16 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: Overturned

Summary Reviewer 3


A 62-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 multiple myeloma is a cancer of plasma cells.  In multiple myeloma, collections of abnormal plasma cells accumulate in the bone marrow, where they interfere with the production of normal blood cells.  Most cases of multiple myeloma exhibit severe anemia.  In addition, these patients will occasionally develop soft tissue tumors composed of abnormal plasma cells.  The hallmark means to diagnose multiple myeloma is via laboratory demonstration of abnormal levels of specific proteins via electrophoresis.  Nonsecretory myeloma is a myeloma subset which is generally characterized by demonstration of monoclonal plasma cells in the bone marrow but with negative results on serum and urine electrophoresis.  In these patients, anemia is less common and renal impairment is rare.  Most of these patients present with symptomatic bone lesions.  As noted by Lonial and Kaufman, imaging with positron emission tomography/computed tomography (PET/CT) scans, and minimal residual disease (MRD) assessment with multi-parameter flow cytometry, may provide newer methods for response assessment, something that has been severely limited in these patients due to the lack of a reliable biomarker. Per the medical evidence, PET scan is a valuable means to evaluate and stage myeloma patients.  Thus, the requested PET scan is likely to be of greater benefit 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 15-year-old male enrollee has requested reimbursement for procalcitonin 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 clinical setting.  Maharajan and colleagues found that procalcitonin is a sensitive and specific marker in the diagnosis of septic arthritis and acute osteomyelitis.  Hunziker and colleagues concluded that serum procalcitonin is a helpful diagnostic marker supporting clinical and microbiological findings for more reliable differentiation of infectious from noninfectious causes of fever after orthopedic surgery.  The evidence-based medical peer-reviewed literature supports the use of procalcitonin level testing for orthopedic patients for differential diagnosis in multiple settings, including distinguishing bacterial infection from inflammatory conditions.  In this case, the use of procalcitonin in follow-up of a left elbow infection after surgical debridement and completion of antibiotic therapy in an adolescent patient is consistent with the literature. Therefore, procalcitonin testing was likely to have been superior over other methods of evaluation.  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 3

A 35-year-old male enrollee has requested authorization and coverage for 64568 and 0466T. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient has already failed CPAP therapy. Multiple studies have demonstrated that hypoglossal nerve stimulation or Inspire airway stimulation improves health for people with obstructive sleep apnea with clinically significant decreases in observed mean apnea-hypopnea index and improvements in quality of life. The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be a safe and effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy. The International Surgical Sleep Society Position Statement states hypoglossal nerve stimulation has been shown to be effective in the treatment of sleep disordered breathing/obstructive sleep apnea in adults when applied to selected patients based on their anatomy, physiology, BMI and neck size, prior therapy and comorbidities. The medical evidence supports the requested services in this clinical setting. Thus, 64568 and 0466T are likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The patient is a 12-year-old female who presented to her provider on 2/22/23. The patients 
parent  has  requested  authorization  and  coverage  for  Genotropin  12  milligram  (mg) 
subcutaneous (SQ) injection cartridge. The Health Insurer has denied this request and reported 
that the requested medication is not medically necessary for the treatment of this patient. The 
physician reviewer found that the submitted documentation does not support the medical 
necessity of the requested medication. The U.S. Food and Drug Administration (FDA) approves 
the use of somatotropin therapy for the treatment of ISS, defined as a height z-score of 2.25 in 
the absence of identifiable pathology. In this case, the patients original clinical presentation and 
subsequent clinical course were most consistent with ISS in the context of a family history 
positive for short stature. Just prior to initiation of daily GH therapy, the patient met generally 
accepted diagnostic criteria for ISS. However, after nearly three and a half years of daily GH 
therapy, the patients most recent PAH after cessation of daily GH therapy had improved 
minimally and still overlapped the normal range for North American women. Given that this 
patients PAH has been normal and consistent with her familial growth pattern, both before and 
after empiric GH therapy for over three years, the requested medication is not medically 
indicated. Therefore, Genotropin 12 milligram (mg) subcutaneous (SQ) injection cartridge is not 
medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 54-year-old female enrollee has requested reimbursement for color-flow Doppler echocardiography performed on 3/29/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees chest pain and dyspnea. The physician reviewer found that there is sufficient support for the services at issue in this patients case. Although in general the evaluation of chest pain in the absence of physical evidence of valvular heart disease or intracardiac shunting can be accomplished without the additional performance of a color-flow Doppler examination with stress echocardiography, there is additional relevant clinical information which may be gleaned from a color-flow Doppler evaluation in the evaluation of unexplained dyspnea, which is the other cardiac symptom that this patient had.  This information includes the presence of pulmonary hypertension as well as intra-atrial shunting among other diagnoses which may be silent on physical examination. The services at issue were appropriate in order to fully evaluate the patients symptoms. Thus, color-flow Doppler echocardiography performed on 3/29/18 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 2

A 56-year-old male enrollee has requested reimbursement for DecisionDx Melanoma testing performed on 11/14/18. 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 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, either as a standard of care or as part of clinical trials. In sum, DecisionDx-Melanoma testing performed on 11/14/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 24-year-old male enrollee has requested reimbursement for Rituxan provided on 12/17/18. The Health Insurer has denied this request and reported that the medication at issue was not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that pediatric autoimmune neuropsychiatric disorder is a term used to describe a patient with OCD or tic disorders which are made worse by group A streptococci. The association between pediatric autoimmune neuropsychiatric disorder and group A streptococci is controversial. Furthermore, the idea that pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS) is an autoimmune disorder is controversial. Immune modulating treatment is not routinely recommended. The treatment of choice for OCD includes cognitive-behavioral therapy, a selective serotonin reuptake inhibitor medication, or both. In this case, the patient has diagnoses of schizophrenia, OCD and PANDAS. Rituximab is an antineoplastic agent, monoclonal antibody immunosuppressant agent. It is not approved by the U.S. Food and Drug Administration for the treatment of OCD, schizophrenia or PANDAS. Therefore, Rituxan provided on 12/17/18 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 32-year-old female enrollee has requested reimbursement for the laboratory testing provided on 6/6/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees miscarriage. The physician reviewer found that there are many causes of recurrent pregnancy loss including parental genetic abnormalities, uterine abnormalities and thyroid dysfunction. While some forms of autoimmune disease, such as antiphospholipid syndrome, have been associated with poor pregnancy outcomes, the role of thrombophilias remains less clear (Kaiser and Branch). The American College of Obstetricians and Gynecologists (ACOG) states that whereas meta-analyses and a retrospective cohort study have revealed an association between inherited thrombophilias and first-trimester pregnancy loss, prospective cohort studies have found no association between inherited thrombophilias and fetal loss. Accordingly, the testing done for serum homocysteine, Factor V Leiden, protein C activity, protein S activity, MTHFR, and prothrombin C20210A mutation was not medically indicated. Thus, the laboratory testing provided on 6/6/16 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 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 24-year-old male enrollee has requested authorization and coverage for cervical spine surgery at the C4-5 level using the Depuy VG2 allograft cervical space and Depuy Synthes Stim-line instrumentation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient presents with progressively worsening and severe neck, right shoulder/arm, and mid-back pain with associated headaches. Signs and symptoms have been reportedly consistent with possible cervical myelopathy, including hand clumsiness and hyperreflexia. His pain is interfering with sleep and activities of daily living. There is imaging evidence of a significant anterior osteophyte at the C5 level with history of superior endplate fracture, and degenerative changes at C4/5 without focal neural compression. There is discogram evidence of severe concordant pain at C4/5. Detailed evidence of a recent comprehensive nonoperative treatment protocol trial and failure has been submitted. The records suggest a history of dysphagia with recent improvement following discogram. Given the persistence of significantly abnormal findings, severe pain and functional limitations, imaging findings of cervical spondylosis with concordant findings at C4/5, and exhaustion of conservative treatment, surgical intervention is medically indicated and supported by evidence-based medical criteria. Therefore, the requested cervical spine surgery at the C4-5 level using the Depuy VG2 allograft cervical spacer and Depuy Synthes Slim-line instrumentation is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 58-year-old female enrollee has requested reimbursement for the DecisionDX uveal melanoma (UM) multigene assay performed on 4/10/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees intraocular choroidal melanoma of the left eye. The physician reviewer found that DecisionDx assay is a study of 15-31 genes in an individuals melanoma cells. It has been used to classify the individuals melanoma as having either a high or low risk of metastasis. It is controversial in cutaneous melanoma as to whether it has additional value when added to the usual pathologic prognostic factors. However, there are medical studies that show the effectiveness of this assay in the analysis of prognosis for uveal melanoma (Onken, et al (2010); Onken et al (2012)). This assay is also within the guidelines of the American Joint Cancer Commission. Specifically, a class 1 category carries with it a less than 20% chance for metastasis, whereas class 2 has a greater than 70% risk of metastasis. This assay has become a standard in many ocular cancer centers and is no longer considered investigational. Its clinical value lies in determining the need for intense surveillance, and possibly to assist in the decision as to adjuvant therapy. Overall, the DecisionDX uveal melanoma multigene assay performed on 4/10/15 was likely to have been more effective than available standard modality for the evaluation of this patient. Based upon the information set forth above, the services 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