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

Summary Reviewer 2

A 35-year-old male enrollee has requested authorization and coverage for 64568 and 0466T. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the patient has obstructive sleep apnea and has no nasal obstruction. Drug-induced sleep endoscopy showed no concentric collapse at velum and primarily anterior posterior collapse. The patient has not been able to tolerate the CPAP device. The Inspire device has been approved by the FDA for the treatment of obstructive sleep apnea. At this point, the patient is a candidate for the Inspire device, given the intolerance to CPAP, anterior posterior collapse, no central apnea, and body mass index (BMI) and apnea-hypopnea index (AHI) within FDA criteria. All told, 64568 and 0466T are likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 37-year-old female enrollee has requested reimbursement for the Afirma thyroid fine needle aspiration (FNA) analysis provided on 1/15/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees pituitary tumor and elevated prolactin.  The physician reviewer found that Thyroid nodules are commonly managed by diagnostic FNA to evaluate the cytopathology. In this case, the finding by this standard technique was atypia of undetermined significance (Baloch, et al). This diagnostic category creates a dilemma with regards to recommended surgery. In this case, the patient was facing total thyroidectomy if malignancy was present and but only subtotal thyroidectomy if the lesion turned out to be benign. Hence, the sample was submitted to Veracyte for gene expression analysis. The Afirma gene expression test conducted by Veracyte has demonstrated a very high negative predictive value for malignancy (Alexander, et al; Chudova, et al). All told, the current peer-reviewed medical literature supports the diagnostic utility of the Afirma thyroid FNA analysis provided on 1/15/15 as 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, I have determined 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 


The patient is a 12-year-old female presenting with class I malocclusion characterized by significant rotations of her anterior teeth. Photographs submitted show the patient to have mild to moderate crowding of her teeth with several teeth rotated causing an aesthetic compromise. The patient shows a class I malocclusion with no excessive overbite or overjet, mild to moderate crowding and rotation of the teeth producing scores below the required score of 26 or greater to be considered a handicapping malocclusion necessitating orthodontic treatment. The patients parent has requested authorization and coverage for orthodontic treatment. The Health Insurer has denied this request as not medically necessary. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the requested services. The patient shows a class I malocclusion with no excessive overbite or overjet, mild to moderate crowding and rotation of the teeth producing scores below the score of 26 or greater to be considered a handicapping malocclusion necessitating orthodontic treatment. The records submitted do not document a medical condition or significant impairment caused by the malocclusion. Based on the documentation submitted for review, the request for orthodontic treatment is not medically necessary for treatment of the patients medical condition. For the reasons provided, the requested services are 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 

The patient is a 50-year-old male who underwent open reduction and internal fixation of a distal radius fracture of the left arm. Postoperatively, the provider prescribed an intermittent limb compression device for edema control. The physician reviewer found that this patient underwent open reduction and internal fixation of a fracture of the distal radius associated with edema. The provider prescribed intermittent limb compression for edema control. Although this device is commonly used for lymphedema control after breast cancer surgery, edema of the upper extremity from a comminuted fracture of the distal radius can also be controlled by this device. Several studies have indicated that this device is safe and effective for upper extremity edema control. It can be used at home as well after discharge from the hospital. Based upon the demonstrated safety and efficacy of this device, it was reasonable, appropriate and medically indicated for the treatment of this patientas left arm edema. Therefore, the intermittent limb compression device provided on 5/17/19 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 59-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 9/26/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found there is sufficient support for the service at issue in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  In sum, breast tomosynthesis performed on 9/26/16 was likely to have been of greater benefit than other methods of evaluating this patient.  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: Overturned

Summary Reviewer 1


The parent of a three-year-old male enrollee has requested reimbursement for the FirstStepDx Plus testing performed on 12/14/15. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees autism spectrum disorder. The physician reviewer found that chromosome microarray is the standard of care for the evaluation of children diagnosed with ASD. The American College of Medical Genetics recommends CMA as an appropriate first-tier test for the evaluation of imbalances associated with intellectual disability, autism, and multiple congenital anomalies. The diagnosis of ASD should be done based on physical exam with a child and evaluation of behaviors. However, finding a genetic cause for the ASD requires further medical evaluation including the CMA. CMA can also provide information on other diagnoses including Angelman syndrome, Williams syndrome or 22q that may overlap with a diagnosis of ASD. Accordingly, the FirstStepDx Plus performed on 12/14/15 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 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 2
A 37-year-old female enrollee has requested reimbursement for the Afirma thyroid fine needle aspiration (FNA) analysis provided on 1/15/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees pituitary tumor and elevated prolactin.  The physician reviewer found that while a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate (Alexander, et al). Until recently, the only way to establish whether the nodule was consistent with cancer was via surgical excision (Miller, et al). The Afirma thyroid FNA analysis from Veracyte utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because the Afirma thyroid test is very sensitive and has a high negative predictive value, a negative result is suggestive of a benign nodule (Duick, et al). Given this support, the Afirma thyroid FNA analysis provided on 1/15/15 was likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined 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: Overturned

Summary Reviewer  
 
The patient is a 42-year-old male with a history of relapsing-remitting multiple sclerosis (RRMS) 
and optic atrophy. The provider has recommended treatment with Vumerity because it has the 
same mechanism of action as dimethyl fumarate, but with fewer gastrointestinal side effects. 
The  Health  Insurer  has  denied  the  requested  medication  as  not  medically  necessary  for 
treatment of the patients medical condition. The physician reviewer found that for patients with 
relapsing forms of multiple sclerosis (MS), disease-modifying therapies (DMTs) have shown 
benefit in terms of reducing relapses. However, adherence to a DMT may be affected by adverse 
effects (Rae-Grant, et al.). The U.S. Food and Drug Administration (FDA) has approved Vumerity 
as a DMT for patients with relapsing forms of MS, including RRMS). Vumerity undergoes the same 
mechanism of action as the delayed-release dimethyl fumarate (Naismith, et al.). The authors 
found that Vumerity demonstrated an improved gastrointestinal tolerability compared with 
dimethyl fumarate. This patient has RRMS and is currently asymptomatic but has cervical spine 
lesions on MRI. The records document that the patient has experienced good response with 
dimethyl fumarate treatment but with adverse effects. Given the similarity of Vumerity to 
dimethyl  fumarate  with  fewer  reported  gastrointestinal  side  effects,  this  medication  is 
appropriate for this patient. Therefore, the requested Vumerity 231 mg capsule is medically 
necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 21-year-old male enrollee has requested reimbursement for corneal collagen crosslinking performed on 9/04/18. 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 sufficient support for the services at issue in this clinical setting. This patient has been diagnosed with progressive keratoconus. The records noted that the patients visual acuity had been decreasing to the point where it interfered with activities of daily living. Keratoconus is caused by a structural abnormality in the collagen of the cornea, wherein the cornea becomes progressively misshapen (astigmatic) over time.  Eventually, this may develop into failure of the cornea, with intractable edema and permanent loss of vision. The classic treatment for keratoconus-induced visual decline is a corneal transplant. This procedure involves risk and the potential for significant complications. Corneal collagen crosslinking is considered to be part of the standard of care for patients with progressing keratoconus, and this involves less risk than corneal transplant. Therefore, corneal collagen crosslinking performed on 9/04/18 was likely to have been more effective than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 61-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device).  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the current medical evidence supports the requested services in this patients case.  The Watchman device is non-inferior to warfarin treatment for long-term stroke prevention due to paroxysmal or persistent atrial fibrillation.  Given this patients recent thromboembolic stroke and known history of paroxysmal fibrillation, as well as higher bleeding risk for systemic anticoagulation, he is an appropriate candidate for the requested services.  Therefore, the requested percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device) is likely to be of greater benefit than other treatment options.  Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3
A 64-year-old female enrollee has requested reimbursement for genetic testing performed on 11/30/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who was diagnosed with breast cancer. The physician reviewer found that the OncotypeDX test is a gene expression assay that generates a DCIS score that may predict the occurrence of ipsilateral invasive breast cancer. The gene expression test was prospectively analyzed in clinical trial E5194, where 327 women with DCIS were stratified into low, intermediate, and high scores, which predicted for either DCIS recurrence or invasive breast cancer in the ipsilateral breast. The test may be used to better assess the utility of radiation therapy after a lumpectomy. The patient under discussion had a complex situation where normal pathology biomarkers were not well suited to address whether a lumpectomy and radiation therapy were appropriate therapies versus total mastectomy.  In sum, the genetic testing performed on 11/30/16 was likely to have been more beneficial than the standard alternatives for evaluation of this patient. Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 59-year-old male enrollee has requested reimbursement for platelet-rich plasma injections provided from 7/14/17 forward. The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that the intra-articular injections of platelet-rich plasma are known to be beneficial in patients with early osteoarthritis as well as advanced osteoarthritis of the knees and other joints. These injections are known to be more efficacious in the treatment of knee osteoarthritis in terms of pain relief and self-reported functional improvement at three, six and 12 months follow-up, compared with other injections such as corticosteroid injections. No harmful effects are reported from these injections. However, in this case, the medical records do not include sufficient clinical and radiographic information necessary to support the necessity of such treatment in the multiple joints that were injected. A detailed history and physical examination and imaging studies are generally necessary to make an accurate diagnosis and determine the necessity of invasive treatment. Official radiology reports indicating the presence of osteoarthritis necessitating such treatment have not been included. In the absence of such clinical and radiographic findings, platelet-rich plasma injections in various joints is not supported. Additionally, the documentation does not indicate a positive sacroiliac diagnostic block confirming the pain source. Ultrasound or fluoroscopic guidance is generally used for sacroiliac injections. However, there is no documentation of the same. With regard to the trapeziometacarpal joints of the thumbs, the literature suggests efficacy in early osteoarthritis, but not in advanced cases. As such, x-rays are necessary. All told, the superior efficacy of platelet-rich plasma injections provided from 7/14/17 forward has not been established. Based upon the information set forth above, the services at issue were not and are not likely to be more beneficial for treatment 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

A 56-year-old female enrollee has requested reimbursement for the three-dimensional (3D) mammogram (breast tomosynthesis) provided on 1/9/17. The Health Insurer has denied this request indicating that the service at issue is considered investigational for evaluation of the enrollees risk of breast cancer.  The physician reviewer found that despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantage it brings radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in overall diagnostic accuracy compared to two-dimensional (2D) imaging alone. Thus, the addition of tomosynthesis to the usual 2D protocol was likely of greater benefit to the patient than had her mammogram been done with 2D imaging alone. As such, the 3D mammogram (breast tomosynthesis) provided on 1/9/17 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 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 49-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of atrial septal defect. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found the requested services are not likely to be more effective for this patient than other available options. Based on an assessment of the peer reviewed literature, the superior benefit of PFO closure versus medical therapy has not been established in cases such as in this clinical setting. The RESPECT trial did demonstrate superiority of PFO closure in patients assigned to the Amplatzer PFO occluder in comparison to guideline directed medical therapy with one or more antiplatelet agents or warfarin (Carroll, et al). However, no significant benefit in the primary intent to treat analysis was documented. In sum, the requested percutaneous transcatheter closure of atrial septal defect is not likely to be more beneficial for treatment of the patients medical condition than any other modalities.Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment 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 59-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 9/26/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that tomosynthesis is a technique that was developed several years ago 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 dense breasts.  The medical literature supports the service at issue in this patients case.  The study by Mansour and colleagues demonstrated that screening sensitivity of full field digital mammography was increased from 60% to 94.5%, and specificity increased from 20.7% to 74% when digital breast tomosynthesis was applied.  Operative bed recurrence could be more confidently excluded from scarring, which reduced the number of indeterminate findings. Digital breast tomosynthesis allowed unnecessary biopsy to be avoided in 37.3% of patients.  Thus, breast tomosynthesis performed on 9/26/16 was likely to have been more effective than other modalities for evaluating this patient.  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.