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

Summary Reviewer 1

A 52-year-old male enrollee has requested reimbursement for proton beam therapy provided from October through December 2016. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees nasopharyngeal carcinoma. The physician reviewer found that there is a lack of clinical data in the medical literature to suggest that treatment with proton beam radiation offers a superior clinical benefit when compared to conventional radiation therapy techniques for tumors of the head and neck area. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy (IMRT). A recent comparative analysis found no significant difference in symptom burden in the acute and chronic phases of treatment with proton therapy was compared to photon therapy for head and neck cancer (Sio).   Also, the ASTRO emerging technology committee report on proton beam therapy specifically states that there is insufficient data to recommend proton beam therapy for routine head and neck radiation therapy outside of clinical trials (Allen, et al). The comparative planning was reviewed and showed no clinically significant benefit with treatment with proton therapy over standard photon techniques as all standard dose metrics are met with the photon plan. In sum, the proton beam therapy provided from October through December 2016 were not likely to have been more efficacious than the standard options available to evaluate this patient. Therefore, for the reasons stated above, the services at issue were not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 54-year-old male has requested reimbursement for genetic testing performed on 2/04/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer.The physician reviewer found that Foundation One testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers than 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 other than KRAS, NRAS, and BRAF mutations. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. Per the medical evidence, Foundation One testing was unlikely to be more beneficial than any available standard therapy such as testing the tumor for standard markers, such as KRAS, NRAS, and BRAF. All told, genetic testing performed on 2/04/16 was not likely to have been superior over other available 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 54-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the right hip. The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found that considering the patients relatively young age and lack of previous trauma, and further considering the severe long-standing deformity and radiographic findings, the records suggest that the underlying problem is a hip dysplasia.  Most commonly, a hip dysplasia is a congenital or developmental deformity or misalignment of the hip leading to chronic arthritis.  There is a role for MRI in the evaluation of hip problems.  Generally, the evaluation of hip pain will begin with plain x-rays.  For hip dysplasia, plain x-rays will often be sufficient, as the displacement will often be readily apparent.  CT scans are often employed as well to confirm the plain x-ray findings.  There are various entities, however, that can only be imaged by magnetic resonance scanning.  Conditions such as labral tears, ligamentous injuries, and subtle osteochondral lesions are only demonstrable with MRI.  Early stage subtle avascular necrosis can also be optimally imaged with MRI.  However, in this patients case, he has very severe osteoarthritis of the hip.  He has no subtle abnormalities.  MRI would be expected to confirm the obvious arthritic change.  All told, the requested MRI of the right hip is not medically indicated for the evaluation of this patient.  Therefore, the requested services are not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer

The patient is a 58-year-old male with a history of uveal melanoma. A tumor sample was submitted for genetic testing with the DecisionDx-UM analysis. The patient has requested reimbursement for the DecisionDx-UM test provided on 8/14/17. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary. DecisionDx-UM is a test that analyzes the genetic profile of a uveal melanoma tumor sample to determine its risk for metastasis. The DecisionDx-UM test stratifies a tumor to low risk and high risk for metastasis. Based on the available medical literature, the DecisionDx-UM is now considered within the standard of care for patients with uveal melanoma. Clinically, it helps determine how intensely a patient needs to be monitored for metastasis. Given these findings, the DecisionDx-UM test provided on 8/14/17 was medically necessary for evaluation of this patients uveal melanoma.  Based on the foregoing discussion, the testing at issue was 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 45-year-old female enrollee has requested reimbursement for the Decision Dx melanoma test performed on 4/4/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma. The physician reviewer found the Decision Dx melanoma test performed on 4/4/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patients tissue underwent Decision Dx testing where the genes are examined for certain markers and then the lesion can be further stratified to tell if there is high risk for metastasis. The treatment of this patient would not change based on the results of the. The test is not considered standard of care. There is a lack of peer-reviewed literature to support its use in the care of patients with thin melanomas to effect health outcomes. In sum, there is a lack of published data to support its use in this clinical setting. Therefore, the testing at issue 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: Experimental
Decision: Upheld

Summary Reviewer 3

A 35-year-old female enrollee has requested reimbursement for homocysteine testing provided on 6/05/18 and 7/16/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who had a history of miscarriage. The physician reviewer found that the current medical evidence does not support the services at issue in this patients case. Recurrent miscarriage is defined as three or more consecutive miscarriages. In this patients case, the records document one miscarriage. Even if she had such a history, this testing is not recommended. According to the American College of Obstetricians and Gynecologists Practice Bulletin Number 197, because of the lack of association between either heterozygosity or homozygosity for the MTHFR C677T polymorphism and any negative pregnancy outcomes, including any increased risk of venous thromboembolism, screening with either MTHFR mutation analyses or fasting homocysteine levels is not recommended. The American College of Obstetricians and Gynecologists does not recommend homocysteine testing in non-pregnant or pregnant women. Thus, homocysteine testing provided on 6/05/18 and 7/16/18 was not likely to have been of greater efficacy 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 
 
A  63-year-old  female  enrollee  has  requested  reimbursement  for  FoundationOne  CDx  TM 
comprehensive genomic profiling test performed on 1/26/21. 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. The hope is that the FoundationOne assay will identify a 
target that would indicate a useful treatment drug. At this time, there is a lack of evidence that 
therapy guided by such assays is likely to be superior to therapy guided by the literature and 
experience. A randomized study by Le Tourneau and colleagues did not indicate that genome 
driven therapy was superior to conventional therapy. Marquart and colleagues indicated that the 
percentage of patients who benefit from assay directed therapy is actually quite low. The use of 
the  FoundationOne  assay  was  not  likely  to  have  been  of  clinical  benefit.  Therefore, 
FoundationOne CDx TM comprehensive genomic profiling test performed on 1/26/21 was not 
likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 24-year-old male enrollee has requested reimbursement for substance use residential treatment center services from 1/21/16 through 2/4/16. The Health Insurer 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 a lack of support for the services at issue in this clinical setting. Upon admission, the patient was experiencing mild post-acute withdrawal symptoms.  By 1/21/16, he was not a danger to himself or others. He was medically and psychiatrically stable. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant residential level of care. He was motivated as evidenced by his active engagement in all aspects of his treatment. The patient was working on relapse prevention and completion of assignments. He was developing insight and coping mechanisms. He was on anti-craving medication.  No new problems had arisen and there was no evidence to indicate that returning him to his environment would lead to destabilization. His family was supportive and participating in his recovery.  Although he continued to struggle with his desire to drink and use, further treatment to further solidify coping skills did not require the structured environment of a residential setting. By 1/21/16, he could have been stepped down to a lower level of care. As such, the residential treatment center services from 1/21/16 through 2/4/16 were not medically necessary. 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 66-year-old male who presented with anterior mediastinal mass measuring 3.6 cm
mass with calcifications. On 7/10/20, he underwent a computed tomography (CT) guided biopsy
of the mass which revealed no evidence of malignancy with benign thymic tissue. The physician reviewer found that the Current National Comprehensive Cancer Network (NCCN) guidelines state that thymoma should
be treated in 60-70 Gy in 1.8 Gy to 2 Gy fraction sizes. The provider has stated his intention of
treating to 70 Gy. Thus, only 35 fractions are considered medically necessary, which would treat
the patient with 2 Gy per day. There is no benefit to treating this tumor at 1.8 Gy per day which
would prolong the entire treatment course by four fractions. In cases of patients requiring doses of
70 Gy to the mediastinum or chest, it is typically standard to treat in 2 Gy fraction sizes. There is
a lack of medical literature to suggest that treatment with 1.8 Gy per day over 2.0 Gy per day is
associated with improved toxicities or improved outcomes. Consensus group guidelines also
support use of 35 fractions in this setting. Therefore, an additional four fractions (treatment
sessions) of IMRT is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer

The patient is a 58-year-old female with osteoporosis of the spine demonstrated on a recent dual-energy x-ray absorptiometry (DEXA). She also has history of hypothyroidism, hypercholesterolemia and breast cancer that has been treated with letrozole. Her provider has recommended Prolia. The patient has requested authorization and coverage for Prolia injection. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination.  The submitted documentation supports the medical necessity of the requested medication. This patient has osteoporosis of the spine. Her risk factors include postmenopausal status, treatment with letrozole, an aromatase inhibitor, and vitamin D deficiency. This patient needs to initiate osteoporosis therapy. This patient is on Synthroid, thyroid hormone replacement, which she must take on an empty stomach. This requirement will be affected by the requirement to take alendronate on an empty stomach as well. Additionally, zoledronic acid is frequently associated with a flu-like syndrome post injection, whereas Prolia has rare side effects. Per the medical evidence, Prolia has a better outcome in prevention of spinal fractures as compared to oral bisphosphonates. There is sufficient support for the requested medication in this clinical setting. Thus, the requested Prolia injection is medically necessary for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 51-year-old female enrollee has requested authorization and coverage for Vemlidy. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B virus. The physician reviewer found that according to the American Association or the Study of Liver Disease (AASLD) guidelines for treatment of hepatitis B, tenofovir is the first-line recommended therapy for the treatment of hepatitis B (Terrault, et al). Per AASLD guidelines, the goal of therapy is long term viral suppression, unless there is clear seroconversion, when applicable, and long-term undetectable viral DNA. In addition, the Vemlidy formulation of tenofovir is effective for hepatitis B and associated with fewer adverse effects, including osteopenia compared to Viread (Grant, et al). For these reasons, Vemlidy is supported as medically necessary for the treatment of the patients hepatitis B infection. 
For the reasons provided, the requested medication is 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 59-year-old female enrollee has requested reimbursement for air and ground ambulance transportation services provided on 4/1/17. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees stage IV squamous cell carcinoma with significant functional decline. The physician reviewer found the air and ground ambulance transportation services provided on 4/1/17 were not medically necessary for treatment of the patients medical condition. There is a lack of support in the peer-reviewed medical literature for the services at issue in this clinical setting. In this case, hospice services were available for the patient in California. The request for air and ground transportation to New Jersey to be closer to family support was not medically necessary for treatment of the patients medical condition. Therefore, 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: Overturned

Summary Reviewer 3 
 
A 49-year-old female enrollee has requested reimbursement for polymerase 
chain reaction (PCR) testing performed on 4/29/19. The Health Insurer has 
denied this request and reported that the services at issue were 
investigational for the evaluation of the enrollees medical condition. 
The physician reviewer found that for a patient who presents with 
symptoms of abnormal vaginal discharge, an examination of the vaginal 
discharge including microscopic evidence of infection can lead to a 
definitive diagnosis.  In the case where microscopy is not available, 
commercial diagnostic testing methods, including PCR testing, are used 
for confirming the clinical suspicion of bacterial vaginosis, vaginal 
candidiasis, or trichomonas vaginitis.  Furthermore, PCR testing  be 
can 
utilized for detecting both gonorrhea and chlamydia. Microscopy is no 
longer widely available in clinic settings, and practices are now relying 
on this testing to diagnose and treat vaginitis. Current studies reported 
sensitivities and specificities of over 96 percent for the detection of  Neisseria gonorrhoeae and Chlamydia trachomatis. Therefore, PCR testing 
performed on 4/29/19 was likely to have been more beneficial than any 
available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 60-year-old female who has a long history of migraines and facial pain. The patient has requested authorization and coverage for cervical spine MRI. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that headaches are a common clinical presentation and often present the patient and the medical practitioner with an issue of when to obtain imaging. Multiple organizations have tried to address this dilemma and have published guidelines. The American College of Radiology has published aAppropriateness Criteriaa for various clinical presentations in order to help guide the practitioner in the most efficacious use of imaging. One of these guidelines is titled aHeadachea, and it is divided into various clinical presentations. The one most closely applicable to this patient is Variant 6, aChronic headache. No new features. No neurologic deficit. Initial imaging.a In this variant, imaging is not recommended. Specifically, MRI is felt to be ausually not appropriatea. Evans and colleagues noted, aIt is not necessary to do neuroimaging in patients with headaches consistent with migraine who have a normal neurologic examination.a Holle and colleagues noted, 
aUsually, neuroimaging is not required in patients with episodic migraine who present with typical headache features according to the classification of the International Headache Society (IHS)aand normal neurologic examination. A meta-analysis of studies with migraine patients showed that in cases with normal neurologic examination and a typical clinical presentation significant brain pathology was only detected in 0.18% of the patients. Therefore, neuroimaging is usually unnecessary in these patients.a There is a lack of support for the requested services in this clinical setting. Therefore, the requested cervical spine MRI is not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
A 40-year-old female enrollee has requested authorization and coverage for thermal destruction 
of intraosseous basivertebral nerve. The Health Insurer has denied this request indicating that 
the requested services are considered investigational for treatment of the insureds spondylosis 
without myelopathy or radiculopathy, lumbar region. The physician reviewer found that when 
Modic changes are present in the disc spaces, the vertebrogenic source is considered an etiology 
of a patients chronic back pain. To address this issue, ablation of the basivertebral nerve has 
been demonstrated to be a safe and effective procedure that is evidence-based for appropriately 
selected candidates. One study noted that based on the U.S. Preventative Task Force (USPSTF) 
criteria for grading evidence, basivertebral nerve ablation has Level A grade evidence with high 
certainty that the net benefit is substantial in appropriately selected individuals (Sayed, et al.). 
Furthermore, a prospective, randomized, multicenter study by Khalil and colleagues highlighted 
that basivertebral nerve ablation led to significant improvement of pain and function at three- months in patients with chronic vertebrogenic related low back pain. In terms of long-term 
results, Fischgrund and colleagues demonstrated basivertebral nerve ablation was associated 
with sustained clinical improvements in pain and improvement in function at a mean of 6.4 years 
following treatment. Standard therapies in this instance would be conservative care with physical 
therapy,  medications,  and  procedural  interventions  such  as  lumbar  medial  branch 
radiofrequency ablation. On review of this patients records, she has failed to improve despite 
adequate attempts at conservative therapies. Given these findings, the requested thermal 
destruction of intraosseous basivertebral nerve is likely to be more beneficial for treatment of 
the patients medical condition than any available standard therapy.