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

Summary Reviewer 


The parent of a 14-year-old male enrollee has requested reimbursement for residential mental health services provided from 2/8/16 through 7/7/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found that per the documentation, the services provided for the RTC included individual therapy once a week, group therapy five times a week, and family therapy once a week. However, the same services could have been provided in a less restrictive treatment environment. The patient did not require 24-hour supervision. He did not have any homicidal or suicidal ideation, there was no evidence that he was a danger to himself or others, and the patient was medically stable. It is noted that during the residential stay, there were few medication changes and his parent consulted with the patients outpatient psychiatrist for all medication changes. The patient could have been treated by the outpatient psychiatrist for any medication changes. Due to the patients autism spectrum disorder, it is likely that his impulsivity will remain a consistent symptom. Prior RTC care did not report that they made much improvement with the patients impulsivity and inappropriate behavior. The expectation as noted in the documentation was that there would be minimal improvement with the patients impulsivity and inappropriate behavior. Therefore, the RTC mental health services provided from 2/8/16 through 7/7/16 were not medically necessary as there was not a reasonable expectation that RTC treatment services would improve the patients problems. Based on the available records, 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 58-year-old female enrollee has requested reimbursement and prospective authorization and coverage for chemical dependency residential treatment services provided from 10/29/18 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees post-traumatic stress disorder (PTSD). The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. On 1/02/19, the patients mood had improved. She had slept well. On this date, therapy continued delving into her history of sexual trauma. The records noted the connection between childhood sexual trauma and substance use. Based on the clinical notes, the patient remained at risk of relapse. Patients conditions wax and wane. A relatively positive documentation on one day does not indicate spontaneous cure. Rather, this denotes progress and that the treatment is working, which is an indication to continue treatment. The American Psychiatric Association treatment guidelines note that residential treatment or similar care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. This patient requires a safe and stable living environment in order to develop her recovery skills. The purpose of detoxification is to make the patient physically stable and safe. Rehabilitation is an essential component that should follow detoxification to help the patient maintain sobriety and reduce risk of relapse. Given the severity of the patients illness and need for detoxification as well as risk factors such as trauma history, residential treatment was and is in accordance with generally accepted standards of medical practice. The current medical evidence supports the services at issue in this clinical setting. Therefore, chemical dependency residential treatment provided from 10/29/18 forward was and is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 64-year-old female has requested reimbursement for FoundationOne testing performed on 1/13/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this patients case.  The study by Von Hoff and colleagues evaluated 86 patients, and the progression-free survival on the regimen selected by molecular profiling was compared to the progression-free survival on the last chemotherapy regimen.  The regimen selected by molecular profiling offered a 27% survival advantage.  This trial has very significant results for patients with stage IV tumors.  In this clinical setting, the results from molecular profiling may offer a rational selection of the next regimen.  Therefore, FoundationOne testing performed on 1/13/16 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 2


A 66-year-old male enrollee has requested reimbursement for the unlisted chemistry procedure (84999) Prometheus Anser testing performed on 12/22/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease.  The physician reviewer found in this case, Anser testing was ordered to direct the management of the patients Crohns disease. The use of Anser testing has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. The effectiveness of Anser testing compared with conventional courses of action remains unproven. Patients being treated with adalimumab may experience loss of response, but 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 (Karmiris, et al; Imaeda, et al; Lichtenstein, et al). These small studies demonstrate correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. The study by Karmiris and colleagues found no direct relationship between trough serum adalimumab concentration or anti-adalimumab antibody and short-term treatment efficacy. 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. A review article concluded that Prospective controlled trials are directly needed to investigate the optimal tailored management in individual patients who lose response (Yanai and Hanauer). Therefore, clinical literature does not support Anser testing as definitively 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 43-year-old female enrollee has requested authorization and coverage for immune globulin injection 500 mg (Gamunex-C). 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 the submitted documentation fails to demonstrate the superior efficacy of the services at issue. The records document a history of recurrent spontaneous pregnancy loss. Per the provider, the patient has been diagnosed with polyclonal hypergammaglobulinemia, white blood cell disorder, and coagulation disorder hereditary thrombophilia. She is currently pregnant, and her provider has recommended intravenous immune globulin (IVIG) (Gamunex-C) to prevent fetal loss. The current literature does not support the services at issue in this patients case. The treatment of IVIG has not been shown to improve pregnancy outcomes. Thus, immune globulin injection (Gamunex-C), 500 mg is not likely to be more effective than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 51-year-old female has requested reimbursement for destruction by neurolytic agent (CPT codes 64635 and 64636) performed on 12/02/13 and 12/23/13.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this patients case.  Lumbar medial branch radiofrequency ablation or neurolysis is a well-documented procedure which may help with chronic low back pain due to lumbar facet pain.  The medical records support the services at issue in this clinical setting.  The literature has noted the effectiveness of medial branch radiofrequency neurotomy in systematic reviews and randomized trials.  In sum, the services at issue performed on 12/02/13 and 12/23/13 were likely to have been more effective than other treatment options.  Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3
A 73-year-old male requested reimbursement for genetic testing performed on 9/26/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma.  The physician reviewer found that the patient is a 73-year-old male with a recurrent squamous cell carcinoma of the scalp diagnosed in 2016 and now with suspected dural invasion. Prior treatment has included multiple Mohs procedures, cetuximab, temsirolimus, and Avastin. His medical history is complicated by heart and kidney transplants for which he is on chronic suppression. FoundationOne testing was sent on 9/26/16 to help guide therapeutic decision making. The patient requested reimbursement for genetic testing performed on 9/26/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational.The National Comprehensive Cancer Network (NCCN) panel encourages participation in a clinical trial for patients with metastatic squamous cell carcinoma. FoundationOne testing helps guide eligibility for clinical trials and help determine eligibility for compassionate use of PDL-1 inhibitors should the tumor express molecular markers indicating likelihood of efficacy. This patients course has been complicated by the use of immunosuppressive medications for his heart and kidney transplant. Accordingly, the genetic testing performed on 9/26/16 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 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 45-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 10/22/15. 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 that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of the dense breast tissue. In this case, the patient has breasts that have been described as being heterogeneously dense. Furthermore, the presence of dense breast tissue is an indication for tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Based on the clinical documentation submitted for review, the breast tomosynthesis performed on 10/22/15 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 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 41-year-old male enrollee has requested reimbursement for Decision DX Melanoma Assay performed on 12/16/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  The prognosis of cutaneous melanoma has classically been determined by the staging system spelled out by Balch.  Mitotic index has also been thought to add a bit more to the prognostics.  Although the pathology report in this case listed his stage as pT1b, it appears that in the absence of ulceration, and a penetration only to Clark Level III, he is really stage pT1a.  By these determinations, he has at least a 95% five-year and 88% ten-year survival.  Decision DX Melanoma Assay is a study of 31 genes in the melanoma cells.  It then classifies that particular melanoma as either class 1 (with a 97% disease free rate at five years) or class 2 (with a 31% disease free rate at five years). Gerami reported that there was good correlation between prognosis and Decision DX classification.  However, it is not clear how Decision DX Melanoma Assay data compares to the ten-year data of Balch determinations, and whether it can be used prospectively in clinical practice. This is especially in question in this particular patient with his pathologic findings and excellent prognosis.  In sum, Decision DX Melanoma Assay performed on 12/16/15 was not likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 59-year-old male enrollee has requested reimbursement for advanced lipoprotein testing provided on 3/11/16. The Health Plan has denied this request indicating that the service at issue was considered investigational for the enrollees hypertension.The physician reviewer found that based on the documentation provided for review the patient presents with significant cardiovascular risk, including diabetes. In this circumstance guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk (Greenland, et al; Stone, et al). Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Accordingly, the advanced lipoprotein testing provided on 3/11/16 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: Experimental
Decision: Upheld

Summary Reviewer 2

A 60-year-old male has requested reimbursement for gene testing provided on 11/07/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The results of this testing were unlikely to have altered treatment recommendations. There is a paucity of evidence from the literature that tailored follow-up according to these test results has an impact on long-term outcomes. Furthermore, prospective randomized studies to determine recurrence risk is lacking for this test. In sum, gene testing provided on 11/07/17 was not likely to have been superior over 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 28-year-old male enrollee has requested authorization and coverage for Genium x 3 (military grade) microprocessor K3 knee. The Health Insurer has denied this request and reported that the requested device is not medically necessary for the treatment of this patient. The physician reviewer found that the current medical evidence does not support the requested device in this clinical setting. The requested device, a microprocessor-controlled prosthetic knee, is not of proven marginal clinical benefit over a conventional prosthetic knee without microprocessor control. The contention that this type of device affords significant functional benefits is largely anecdotal or industry-generated/supported. A clinical trial by Meier and colleagues showed higher performance with a passive prosthetic knee (Mauch SNS) versus the microprocessor-controlled C-Leg. The authors postulated that a simpler knee joint could perform better than a microprocessor-aided prosthetic knee on soft or uneven surfaces because users have a more expedient and direct impact on the knees behavior over a microprocessor-aided knee. More recent high-grade literature establishing a clinically significant functional improvement using this technology has not been published. Therefore, the requested Genium x 3 (military grade) microprocessor K3 knee is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 57-year-old male enrollee has requested authorization and coverage for PET imaging (78816). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the management of incidentally discovered cystic pancreatic lesions depends on multiple factors, including size, morphology/location, presence of a solid component, communication with the pancreatic duct and the presence of high-risk features. Depending on these characteristics, appropriate management could include surgical resection, biopsy (if amenable) or serial follow-up imaging. In this case, the computed tomography scan could not determine if this lesion communicates with the pancreatic duct. The next appropriate imaging test would be magnetic resonance imaging/magnetic resonance cholangiopancreatography to assess ductal relationship and therefore determine follow-up and further management. The medical evidence does not support the requested services in this clinical setting at this time. Therefore, PET imaging (78816) is not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1A 56-year-old male enrollee has requested reimbursement for FoundationOne testing performed on 3/14/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees recurrent myxofibrosarcoma.  The physician reviewer found that Currently recognized and accepted molecular evaluation and classification of soft tissue sarcoma (STS) include standard histological evaluation (National Comprehensive Cancer Network guidelines). Broad genomic panel testing such as FoundationOne is not considered standard therapy. In general, to demonstrate clinical utility of panel genetic testing, such as FoundationOne, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. There is currently a lack of such trials that have been published. The available literature on clinical utility consists of a small number of uncontrolled studies, and nonrandomized controlled trials that use imperfect comparators. This evidence is not sufficient to make any conclusions as to its clinical utility in this patients case. In addition, there is potential for harm if ineffective therapy is given based on test results, because there may be adverse effects of therapy in absence of a benefit. As a result, the use of expanded mutation panel testing for targeted treatment in cancer is considered unproven and should only be conducted in the setting of a clinical trial. Accordingly, FoundationOne testing performed on 3/14/17 was not likely have been of greater benefit than the standard options available for the evaluation of this patients medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The 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 the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The medical literature supports CGH to be performed as the initial investigative tool for evaluating children with developmental delay (Michelson, et al). CGH is well established as the initial assessment study for any developmentally delayed child. The testing at issue was clinically indicated as it is the most effective tool available for establishing an etiology in this clinical setting. For the reasons provided, the comparative genomic hybridization (CGH) FirstStep DX Plus testing performed on 10/15/15 was likely to have been 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.