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

Summary Reviewer 3

A 25-year-old female enrollee has requested reimbursement for calprotectin fecal laboratory testing (CPT 83993) performed on 12/24/20.  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 thant the submitted records fail to demonstrate the superior efficacy of the services at issue. Providers use the clinical history along with laboratory studies to obtain clues to ongoing inflammation related to the suspecting an underlying disorder of inflammatory bowel disease (IBD). In addition, radiographic studies and endoscopic evaluation are tools that can be used but carry their own potential risks. This patient underwent fecal calprotectin to assess the level of inflammation. An elevated fecal calprotectin is not specific for IBD. Any inflammatory process within the gastrointestinal tract will result in the activation of the innate immune response and release of calprotectin. Fecal calprotectin concentration has been shown in studies to be elevated in many conditions, including rheumatologic conditions. Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to cause significant increases in fecal calprotectin levels. Proton pump inhibitors (PPIs) have been associated with significantly elevated fecal calprotectin levels, regardless of reason for PPI. Therefore, calprotectin fecal laboratory testing (CPT 83993) performed on 12/24/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


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 this patient has Crohns disease, for which she had a colectomy and has been maintained on Humira.  However, she had ulcerations in the terminal ileum which would be concerning for active disease on Humira.  The testing at issue evaluates for adalimumab blood level and for antibodies to adalimumab.  Due to the multitude of management options once a patient has no response to Humira and the fact that Humira has a wide array of adverse effects, it is important for the treating provider to have a roadmap of the nature of the patients clinical course.  Thus, Anser ADA testing performed on 1/16/15 was likely to be of greater benefit than other alternatives.  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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 50-year-old female enrollee has requested authorization and coverage for stretching devices (E1830 and E1399). The Health Insurer has denied this request indicating that the requested devices are not medically necessary for treatment of the enrollees medical condition status post hammertoe correction. The physician reviewer found that the requested Dynasplint toe flexion system stretching devices are not medically necessary for treatment of the patients condition. There is a lack of sufficient evidence in the published medical literature to permit conclusions on the safety, efficacy and long-term outcomes of the proposed stretching devices. In this case, the use of static progressive stretch splint devices alone or combined with standard physical therapy is not medically necessary. In addition, there is a lack of documentation demonstrating that the patient is unable to benefit from standard physical therapy modalities because of an inability to exercise or the patient has participated in a treatment plan with documentation of no improvement for four months. Moreover, the use of patient-actuated serial stretch and bi-directional static progressive devices is not the standard of care in this clinical setting. All told, the request for stretching devices (E1830 and E1399) has not been established as medically necessary for the patients medical condition.  Therefore, the requested devices are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3 
 
A 64-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 8/14/19. 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 staging and prognosis of cutaneous melanoma has classically been 
determined by applying the system spelled out by Balch. Mitotic index may add a bit to these 
statistics. DecisionDx-Melanoma testing is an assay of 31 genes in a particular melanoma. It then 
places that particular melanoma into either Class 1 or 2, with somewhat different risks of 
metastasis by five years. It is not clear how the five-year DecisionDx-Melanoma data compares 
to the ten-year Balch data. Most importantly, it has not been shown that one can use the 
DecisionDx-Melanoma data to make important clinical decisions, such as the need for sentinel 
node biopsy or the use of adjuvant therapy. Therefore, DecisionDx-Melanoma testing performed 
on 8/14/19 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 45-year-old female enrollee has requested has requested reimbursement for intravenous immune globulin (IVIG) treatment provided from 3/14/16 through 4/22/16. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees chronic inflammatory demyelinating polyneuropathy (CIDP). The physician reviewer found that IVIG is U.S. Food and Drug Administration (FDA) approved for the treatment of CIDP. In this case, the patient is diagnosed with CIDP and has had a good response to IVIG treatment with improved strength and activities of daily living. The delay in administration of IVIG treatment caused the CIDP to relapse. These findings support the medical necessity for IVIG treatment. As such, IVIG treatment provided from 3/14/16 through 4/22/16 has been established as medically necessary for treatment of the patients medical condition.  Therefore, the medication at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 62-year-old female enrollee has requested reimbursement for hospital services provided on 2/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees dislocated thumb. The physician reviewer found the inpatient admission was not medically necessary in this patients case. Inpatient care is necessary when the patients signs, 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 and could have been treated at a lower level of care. The documentation provided did not support acute exacerbations of chronic medical problems. The records indicated that the patients pain was controlled. She could have been treated at a lower level of care for the procedure. Per InterQual criteria for acute inpatient admission, the criteria was not met? in this patients case. As such, the hospital services provided on 2/6/17 were not medically necessary for the treatment of this patients medical condition. Therefore, for the reasons stated 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 3

A 76-year-old male enrollee has requested reimbursement for the Oncotype DX Colon Cancer Assay (CPT 81525) performed on 10/25/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees stage II colon cancer. The physician reviewer found that it has been demonstrated in the medical literature that adjuvant chemotherapy is beneficial to patients with stage III colon cancer. However, the usefulness of adjuvant chemotherapy in patients with stage II cancer remains controversial. Some of the features that have been associated with a higher risk of recurrence in node-negative patients include poorly differentiated cancer, lymphovascular invasion, presentation with obstruction or perforation, or a T4 tumor (Rodriguez, et al). However, this patient has none of these features. In the absence of these high risk feature, the Oncotype DX Colon Cancer Assay (CPT 81525) performed on 10/25/17 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 

The patient is a 60-year-old male who has been diagnosed with moderate to severe ulcerative colitis (pancolitis). The patient has requested authorization and coverage for Remicade 10 mg/kg every six weeks for eight months. The Health Insurer has denied this request and reported that the requested medication dosage is not medically necessary for the treatment of this patient. The physician reviewer found that Remicade (infliximab) is FDA-approved and recommended for the treatment of ulcerative colitis. The increased dose requested in this case is commonly required during maintenance therapy with infliximab, and it can be effective. Large studies have shown that disease can be maintained in a majority of cases with increase of dose. American College of Gastroenterology guidelines for management of ulcerative colitis support the requested increase in Remicade dosage in patients with uncontrolled disease.  Additionally, American Gastroenterological Association guidelines for management of ulcerative colitis support the requested increase in Remicade dosage in patients with low Remicade level if anti-Remicade antibodies are absent or at a low level, as in this case. The American Gastroenterological Association guidelines for therapeutic drug monitoring state that a Remicade level of 5 ug/mL is recommended, and over 10 ug/mL is highly likely to be effective; the level in this case is significantly lower. Although the patient does not have frankly uncontrolled clinical disease, there is a history of dysplasia and of pseudopolyps, which place the patient at risk for colorectal cancer and severe disease flare.  For these reasons, an increase in dose to 10 mg/kg every 6 weeks is supported by current medical literature and guidelines. If therapy is continued at the current dose with low drug level, there is risk for a disease flare, uncontrolled disease, or uncontrolled disease manifesting as dysplasia and leading to colon cancer. Therefore, Remicade 10 mg/kg every six weeks for eight months is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 37-year-old female enrollee has requested authorization and coverage for lymphaticovenous anastomosis and intraoperative indocyanine green lymphatic mapping. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. Baltzer and colleagues stated, aPatient selection is key to the success of lymphovenous anastomosis. Patients are selected who have clinical stage 1 or 2 lymphedema using the International Society for Lymphology classification. Patients who have been compliant with nonoperative measures and do not demonstrate considerable improvement in symptoms and quality of life should be considered for surgery. Proximal lymphedema can also improve after lymphovenous anastomosis performed in the distal extremity.a Akita and colleagues stated, aVascularized supraclavicular lymph node transfer is an effective technique for the treatment of advanced stage lower extremity lymphedema. Lymphaticovenular anastomosis is also effective, but to a lesser degree than vascularized surgical lymph node transfer. However, lymphaticovenular anastomosis is less invasive and requires a shorter hospital stay.a Lymphovenous anastomosis is an established surgical treatment for lower extremity lymphedema. Therefore, lymphaticovenous anastomosis and intraoperative indocyanine green lymphatic mapping is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 54-year-old male enrollee has requested reimbursement for the Prometheus diagnostic panel performed on 11/24/15. 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 that the Prometheus diagnostic panel performed on 11/24/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. To assist in the diagnostic evaluation of patients with suspected IBD, serologic testing is utilized to accurately distinguish patients with IBD from patients with other gastrointestinal disorders. The Prometheus diagnostic panel examines the patterns among multiple classes of markers. This approach is indicated in cases that pose a diagnostic challenge and where the presentation remains confounded despite endoscopic and pathologic testing such as in this patient. Therefore, the testing at issue 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: Overturned

Summary Reviewer 


A 45-year-old female enrollee has requested authorization and coverage for arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees back pain. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this clinical setting. This patient presents with persistent severe right greater than left SI joint pain. Functional difficulty was documented in sitting tolerance, activities of daily living, and work ability. She was status post circumferential L3-S1 instrumented fusion in May 2014 with initial positive surgical benefit allowing return to work. She reported progressively worsening bilateral buttocks pain. There was evidence of long-term conservative treatment including medications, activity modification, SI joint injections, sacroiliac radiofrequency ablation, and physical therapy without sustained improvement. Clinical examination findings have documented SI joint tenderness with four positive sacroiliac provocative testing. There was radiographic evidence of bilateral sacroiliac arthropathy, right greater than left, consistent with adjacent segment degeneration. Multiple SI joint injections have been documented with 100% relief on the day of injection and diminishing response over time. In this patients case, the current evidence based medical guideline and peer-reviewed surgical indications for SI joint fusion have been met. In sum, arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance is medically necessary for treatment of this patient. Therefore, for the reasons stated above, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 45-year-old male who has been diagnosed with psoriasis with total body surface area of greater than 10%, severely affecting his quality of life. He has tried and failed various topical therapies as well as phototherapy. The physician reviewer found that Psoriasis is a chronic inflammatory skin disease. Patients typically present with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. The long-term use of traditional systemic therapies is frequently unacceptable because of renal, hepatic, pulmonary toxicity and limited efficacy. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities.
The U.S. Food and Drug Administration has approved secukinumab (Cosentyx) to treat adults with moderate-to-severe plaque psoriasis. In clinical trials, subcutaneous secukinumab was more effective than placebo, etanercept and ustekinumab at improving psoriasis symptoms (with high skin clearance). Secukinumab was more effective than placebo in studies specifically investigating efficacy in the difficult-to-treat palmoplantar and nail psoriasis populations. Studies specifically
investigating drug efficacy in these populations are rare, and treatment options for these patients are limited. Therefore, Cosentyx 300 mg dose, two pens are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary  
The patient is a 52-year-old female with a history of refractory back pain, depression, anxiety, 
and chronic pain disorder status post pain pump placed in 2019. The provider has recommended 
placement of a percutaneous implantation of spinal cord stimulator. The physician reviewer 
found that at issue is whether the requested percutaneous implantation of neurostimulator 
electrode array, epidural, is medically necessary for treatment of this patient. A prospective, 
multicenter, randomized controlled trial was conducted evaluating the long-term quality of life 
improvement for patients with chronic intractable back and leg pain using spinal cord stimulation 
(Amirdelfan, et al.). The authors reported that of the 171 patients who received a permanent 
spinal cord stimulation device implant, a higher proportion of spinal cord stimulation patients 
had marked improvement of their disability on the Oswestry Disability Index (ODI) to a moderate 
or minimal impact on their daily function versus the control group. The authors concluded that, 
In  addition  to  superior  pain  relief,  10  kHz  spinal  cord  stimulation  provides  long-term 
improvements in quality of life and functionality for subjects with chronic low-back and leg pain. 
Similarly, a systematic review and meta-analysis performed by Head and colleagues evaluated a 
variety of spinal cord stimulation systems and device parameters for use in patients with chronic 
low back and leg pain. The authors concluded that data from level 1 randomized controlled trials 
have elevated the status of spinal cord stimulation to a safe and effective alternative for the 
treatment of neuropathic low back pain and leg pain. In this case, the patient has chronic low 
back pain that has been non-responsive to medication management, physical therapy, epidural 
steroid injections, cognitive therapy and intrathecal pain pump. Based on the level one evidence 
to support the usage of spinal cord stimulation therapy for patients with chronic low back and 
leg pain that is refractory to other forms of conservative care, the requested spinal cord 
stimulation is appropriate for treatment of this patients chronic low back pain. Therefore, the 
requested percutaneous implantation of neurostimulator electrode array, epidural, is medically 
necessary for treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 29-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. Skubleny and colleagues concluded, aLong-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation.a Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia, requiring endoscopic intervention. Sheu and Rattner concluded, aThe long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined.a LINX has significant potential adverse effects and can be associated with poor outcomes. Therefore, the requested LINX procedure is not likely to be more beneficial than any available standard therapy.