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

Summary Reviewer  
 
The patient is a 61-year-old male with persistent, symptomatic atrial fibrillation with multiple 
hospital visits for chemical cardioversion. The patient has requested authorization and coverage 
for hybrid convergent ablation treatment of atrial fibrillation (CPT 33266). The physician reviewer 
found  that  the  hybrid  convergent  procedure  has  superior  effectiveness  compared  with 
endocardial-only ablation in patients with advanced atrial fibrillation. This was demonstrated in 
the CONVERGE trial, a multicenter, randomized clinical trial which also showed a significantly 
higher number of patients in the hybrid convergent arm remaining free from cardioversion at 18 
months follow-up. This was also associated with an acceptable safety profile. The cumulative 
experience with the convergent procedure is now greater than 10,000 patients to date and has 
an established position in managing atrial fibrillation. Therefore, hybrid convergent ablation 
treatment of atrial fibrillation (CPT 33266) is medically necessary for treatment of the patients 
medical condition.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 41-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 1/17/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of
invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is very novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Therefore, DecisionDx-Melanoma testing performed on 1/17/20 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 




The parent of a 16-year-old male enrollee has requested reimbursement for mental health outpatient services provided from 11/25/15 through 5/12/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). The physician reviewer found that reviewing therapy progress notes including those from 11/25/15, 12/17/15 and 3/17/16 it was consistently noted that the patient had restlessness, depression, but there was no documentation of any evidence that would warrant extended outpatient sessions. There was no indication that the patient was in crisis or decompensating, or that he required specialized services that would require extended sessions. Overall, the records provided for review suggest this patient could have been reasonably and adequately treated with less intrusive, less invasive level of care, such as regular outpatient therapy sessions. Accordingly, the mental health outpatient services provided from 11/25/15 through 5/12/16 were not medically necessary for treatment of this patients medical condition. Based on the records provided, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 63-year-old female enrollee has requested reimbursement for gene testing (breast cancer index test) performed on 7/16/18. 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 BCI is a combination of two profiles, the HOXB13-to-IL17BR expression ratio (H:I ratio) and the Molecular Grade Index (MGI). Compared with clinical prognostic factors, such as age, tumor size, tumor grade, and lymph node status, the H:I ratio was significantly and independently correlated with outcome. Subsequent studies have validated the BCI as an accurate predictor of endocrine responsiveness among patients with estrogen receptor positive breast cancer, with one case-control study suggesting it may identify those who would benefit from extended endocrine therapy. The American Society of Clinical Oncology (ASCO) supports use of the BCI. The National Comprehensive Cancer Network guidelines noted, For patients with T1 and T2 hormone receptor-positive, HER2-negative, and lymph node-negative tumors, a BCI in the low-risk range, regardless of T size, places the tumor into the same prognostic category as T1aT1b, N0, M0. Results of a secondary analysis of the aTTom trial demonstrated that in patients with hormone-receptor positive, node-positive breast cancer, patients with a high BCI (HOXB13/IL17BR) (H/I) derived significant benefit from extending tamoxifen therapy to 10 years versus five years. In contrast, BCI (H/I) low patients derived no benefit from extended adjuvant therapy. This patient fits in the latter category, and the results may allow her to come off of endocrine therapy, for which she experiencing side effects. The medical evidence supports the services at issue in this clinical setting. Therefore, gene testing (BCI test) performed on 7/16/18 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1
A 48-year-old female enrollee has requested authorization and coverage for implantation of Strattice. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees abdominal hernia. The physician reviewer found that there is support in the literature for the efficacy of the requested services in this clinical setting. Based on the overall documentation provided for review, the patient has failed standard therapy for correction of her complex abdominal hernia.  She has failed primary repair with synthetic mesh, as the mesh had become infected and had to be removed. This patient has evidence of a symptomatic, recurrent, left lower abdominal hernia.  She has a history of severe trauma and multiple reconstructive procedures of her abdomen.  She has noted to have failed previous mesh placement, as it had become infected and had to be removed.  Currently, she is symptomatic from her hernia with chronic pain, treated with an abdominal binder and chronic opioid use.  The requested Strattice (porcine biologic mesh) is used to reinforce the abdominal reconstruction provided by autologous tissue.  Strattice is a bioprosthetic porcine mesh. The medical literature indicates that bioprosthetic materials are preferred over synthetic materials for use in contaminated fields and should be strongly considered when the defect has bacterial contamination.  Patel and colleagues noted, Strattice is an effective adjunct to AWR (abdominal wall reconstruction) when used as reinforcement during CS (component separation) for a wide variety of indications. Complication rates remain low in complex patients. In addition, Strattice appears to add durability to midline reconstructions with no recurrences during the follow-up period.  In summary, this patient has exhausted standard therapy and Strattice has been shown to provide benefit in abdominal wall reconstruction. As such, implantation of Strattice is likely to be superior to the standard options available for 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 20-year-old female enrollee has requested reimbursement for the wilderness therapy program received from 5/22/15 through 8/3/15.  The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that there is lack of support in the literature for the medical necessity of the services at issue in this clinical setting. In an article by Widmer and colleagues, the authors noted that while some studies report benefits of wilderness therapy, caution should be exercised in the interpretation of these results. In order to establish its efficacy, a multi-centered, highly-powered, randomized controlled trial would need to be performed. Currently, there are not enough studies to indicate that wilderness therapy is effective in the treatment of depression and anxiety over standard therapies. In addition, from the records provided, there was a lack of oversight by a child and adolescent psychiatrist, and there were no nursing staff to properly administer medications and monitor the patients. Accordingly, based on the medical literature, wilderness therapy received from 5/22/15 through 8/3/15 did not meet the standard of care for the treatment of depression, anxiety, and substance use. As such, the wilderness therapy program received from 5/22/15 through 8/3/15 was not medically necessary for treatment of this patients medical condition. Therefore, based on the information noted above, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

The patient is a 62-year-old male with a progressive neurodegenerative disease with ataxia, dysarthria, fatigue and cognitive dysfunction. The patient had an abnormal magnetic resonance imaging (MRI) in the past with localized atrophy. His provider suspected the diagnosis of multisystem atrophy versus spinocerebellar atrophy and 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.  While a DaT SPECT study is not indicated for all patients with degenerative diseases, it has been shown to be useful in cases where the diagnosis of Parkinsons disease (or a Parkinson plus syndrome such as multisystem atrophy) versus another non-dopaminergic degenerative disorders (such as spinocerebellar atrophy) is being considered. These diseases can be challenging to differentiate based only on clinical grounds. In this particular case, the DaT SPECT scan provided definitive information.  It is imperative to provide a definitive diagnosis as treatment for multisystem atrophy, Parkinsons disease, and spinocerebellar atrophy are quite different and a trial of an unnecessary therapy would place the patient at risk of significant side effects.  There is some support in the medical literature demonstrating the use of this study in differentiating patients with movement disorders.  Thus, DaT SPECT scan of the brain performed on 9/23/16 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 3

The patient is a 62-year-old female with metastatic urothelial cancer. She presented with right hydronephrosis and an irregular bladder wall. This was bladder cancer at stage T4. She underwent transurethral resection of bladder tumor and was treated with gemcitabine and cisplatin. By June 2017, she had a right inguinal lymph node that had metastatic urothelial cancer. A staging computed tomography (CT) in July 2017 showed extensive abdominal lymphadenopathy with evidence of diffuse metastatic disease. A tumor sample was submitted to FoundationOne for mutational testing. The patient has requested reimbursement for the FoundationOne gene test provided on 8/15/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational. One standard regimen for advanced bladder cancer is methotrexate, vincristine, doxorubicin, and cisplatin (MVAC) (Sternberg, et al). Regimens with fewer drugs have been compared head-to-head with MVAC but have not performed as well in terms of survival advantage but have demonstrated reasonable response rates (Mead, et al; Hillcoat, et al). Von Hoff and colleagues reported on a study of 86 patients where the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The authors noted that the regimen selected by molecular profiling offered a 27% survival advantage. This trial has very significant results for patients with stage IV tumors. Given this support, the FoundationOne gene test performed on 8/15/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 38-year-old female enrollee has requested authorization and coverage for matrix autologous chondrocyte implantation, up to three days in hospital stay and growth of cartilage from her knee. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees osteochondral defect. The physician reviewer found the peer-reviewed literature demonstrates that autologous chondrocyte implantation of the talus yields improvement in all parameters tested with enduring long-term results in patients who have failed previous surgery for osteochondral lesions of the talus. In this case, the patient has undergone multiple surgeries on the cystic osteochondral lesion of the talus with persistent severe pain. Significant limitation is documented in activities of daily living, work activities, and recreational pursuits. Detailed evidence of long-term reasonable and/or comprehensive non-operative and operative treatment and failure has been submitted. There is imaging evidence of an osteochondral defect of the medial talar dome, measuring 9 x 9 x 8 mm. Autologous chondrocyte implantation of the talus is supported by a significant volume of literature for patients who have failed previous surgery for osteochondral lesions of the talus. Therefore, the request for matrix autologous chondrocyte implantation, up to three days in hospital stay and growth of cartilage from her knee, 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: Upheld

Summary Reviewer 1

A 59-year-old female enrollee has requested reimbursement for high dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, for dates of service 2/07/19, 2/09/18, 2/12/19, 2/14/19, 2/19/18, 2/21/18, 2/26/18, 2/28/18 and 3/05/18. 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 there is a lack of support for the services at issue in this patients case. The records document squamous cell carcinoma of the skin. Per the most current American Brachytherapy Society Consensus Statement: At this time, there are growing data with respect to electronic brachytherapy and non-melanomatous skin cancer; however, there is a lack of comparative data to traditional treatments, limited data with long-term follow up, and a need for younger patients in studies before generalizing recommendations. Although data can be extrapolated from orthovoltage experiences with non-melanomatous skin cancer, in light of the large numbers of patients diagnosed with non-melanomatous skin cancer, prospective studies with larger numbers of patients undergoing electronic brachytherapy should be performed. National Comprehensive Cancer Network guidelines support these recommendations. Therefore, the superior efficacy of high dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, for dates of service 2/07/18, 2/09/18, 2/12/18, 2/14/18, 2/19/18, 2/21/18, 2/26/18, 2/28/18 and 3/05/18 has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 37-year-old male enrollee has requested reimbursement for an ultrasound provided on 4/05/18. 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 liver fibrosis is an important prognostic factor in patients with chronic hepatitis B, and assessment of the stage of liver fibrosis is important in management. Ultrasound with elastography offers a noninvasive alternative to biopsy for the assessment of liver fibrosis, with comparable diagnostic accuracy, but also can identify patients with subclinical cirrhosis who are at increased risk of developing hepatocellular carcinoma, even when cirrhosis is not clinically apparent. Elastography is a noninvasive alternative to liver biopsy for this assessment, and avoids the invasiveness, risk of complications, and sampling error associated with liver biopsy. The American Gastroenterological Association (AGA) Institute guideline for elastography states, In patients with chronic hepatitis B, the AGA suggests vibration-controlled transient elastography rather than other nonproprietary noninvasive serum tests to detect cirrhosis. By avoiding the complications of liver biopsy, and allowing for appropriate management of chronic hepatitis B (which differs depending on whether cirrhosis is present), elastography can result in improved health outcomes. For these reasons, ultrasound with elastography was medically indicated for the management of this patients chronic hepatitis B. Therefore, the ultrasound with elastography performed on 4/05/18 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 49-year-old female enrollee has requested reimbursement for a digital breast tomosynthesis that was performed on 3/22/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for the enrollees breast examination The physician reviewer found there is evidenced base 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 was likely to be 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 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 22-year-old female enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 1/16/15. 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 the use of Anser ADA has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility.  In this case, Anser ADA was ordered to determine the etiology for possible loss of response and reaction to Humira, and to direct the management of the patients Crohns disease.  The effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with adalimumab may experience loss of response. However, loss of response can be due to multiple factors, and the appropriate method for determination of the cause for loss of response is not clear.  The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature.  These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking.  Therefore, Anser ADA testing performed on 1/16/15 was not likely to have been superior over other modalities for 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 1


The parent of a five-year-old male enrollee has requested reimbursement for the comparative genomic hybridization (CGH) FirstStep DX Plus testing performed on 10/15/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that according to Slavotinek, Array comparative genomic hybridization (array CGH) has revolutionized the cytogenetic testing available for patients with learning disabilities who have chromosomal phenotypes with dysmorphic features and multiple anomalies. Screening large patient cohorts with mental retardation by array CGH has recently lead to the characterization of many novel microdeletion and microduplication syndromes, initially according to the shared cytogenetic aberrations, with secondary characterization of the corresponding phenotypes. The author further states that, it is clear that array CGH has heralded an unparalleled era of discovery for clinical cytogenetics. Data have now emerged showing that actionable findings from chromosomal microarray justify its use. Given the support in the peer-reviewed literature, the comparative genomic hybridization (CGH) FirstStep DX Plus testing performed on 10/15/15 has been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.