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

Summary Reviewer 3

A 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/17/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is very novel and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Therefore, DecisionDx-Melanoma testing performed on 5/17/19 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 61-year-old female 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 there is a lack of support for the requested services in this patients case. She has moderate obstructive sleep apnea. The documentation notes that the patient is intolerant to continuous positive airway pressure therapy. The records do not clearly establish that the patient is not a candidate for oral appliance therapy. Mild to moderate obstructive sleep apnea has been shown to be responsive to oral appliance therapy. Thus, 64568 and 0466T are not likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 44-year-old female enrollee has requested authorization and coverage for the Intracept 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 sparse amount of published clinical data to support the use of this treatment modality.  An industry sponsored trial by Becker and colleagues involved 17 patients who were treated for refractory chronic low back pain. The authors concluded, aAblation of the basivertebral nerve for the treatment of chronic lumbar back pain significantly improves patientsa self-reported outcome early in the follow-up period; the improvement persisted throughout the one-year study period.a Fischgrund and colleagues performed a multicenter randomized control trial involving 225 patients with refractory low back pain. The authors noted, aPatients treated with radiofrequency ablation of the basivertebral nerve for chronic low back pain exhibited significantly greater improvement in Oswestry Disability Index (ODI) at three months and a higher responder rate than sham treated controls.a While there is a small amount of supporting data which suggests some short-term patient reported outcomes with the Intracept procedure, some of this data is industry sponsored. The single randomized controlled trial demonstrates some potential short-term benefit, but is lacking long-term efficacy and safety data. Clinical conclusions on this procedureas safety and efficacy require longer-term safety and efficacy data prior to accepting it as standard of care. Thus, the requested Intracept procedure is not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


An 18-year-old female enrollee has requested reimbursement for mental health residential treatment center (RTC) services provided from 2/4/15 through 4/24/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees bipolar disorder, parent-child relational problem, and cannabis abuse. The physician reviewer found that based on the records provided for review, the criteria for RTC services from 2/4/15 through 4/24/15 have not been met. The patient did not have any suicidal or homicidal ideations, there was no evidence of psychosis, and she had no self-injurious impulses during the course of treatment documented. Additionally, no medication changes were made during the course of admission that required 24-hour supervision. The records suggest the patient could have been treated safely and effectively in a less intrusive, less invasive level of care such as outpatient medication management and outpatient therapy during this period of time. Accordingly, the RTC services provided from 2/4/15 through 4/24/15 were not medically necessary. Based on the foregoing discussion, 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

The patient is a 19-year-old female who has been recognized to have a number of inherited disorders, including intellectual disability, multiple congenital anomalies including, coarctation of the aorta and small left ventricles unbalanced atrioventricular canal defect and short stature. The patient underwent genetic testing in order to obtain additional information and to best guide medical management of her care. The patient has requested reimbursement for FirstStepDX Plus test rendered on 4/14/17. The Health Insurer has denied the request for reimbursement. Per the Health Insurer, the services at issue were investigational.  There is support in the medical literature for the efficacy of the tests performed in April 2017. The provider ordered testing to gather additional information that could affect the care and treatment of this patient. The records show that the patients clinical presentation is not specific to a well delineated syndrome and she has two or more major malformations. As such, targeted genetic testing is relevant as a rationale pursuit of information that could potentially alter treatment services. All told, the FirstStepDX Plus test rendered on 4/14/17 was likely to have been more efficacious for evaluating this patients medical condition when compared to other available standard options. 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: Overturned

Summary Reviewer 3

A 45-year-old male enrollee has requested reimbursement for ipilimumab and nivolumab provided on 6/11/19, 7/02/19, 7/23/19 and 8/13/19. The Health Insurer has denied this request and reported that the medications at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the medications at issue in this clinical setting. In patients with widespread metastatic renal cell cancer, this combination of immunotherapy drugs is superior to more standard therapy, and is currently the recommended treatment. The medullary variant is a rare variant, and there is less data concerning this type. Nonetheless, this combination was likely to have been more effective than other treatment alternatives. Thus, ipilimumab and nivolumab provided on 6/11/19, 7/02/19, 7/23/19 and 8/13/19 were likely to have been more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

The patient is a 55-year-old female with a history of rheumatoid arthritis. On 8/18/16, she was being treated with methotrexate, prednisone and Xeljanz.  Per the records, Xeljanz had improved her symptoms, but she was having more frequent outbreaks of herpes.  During the past month, she had experienced pain in her right elbow, worse back pain, left ankle pain/stiffness and weight gain.  The records noted that the patient has responded to Remicade in the past, although this was discontinued due to cost. The patients provider recommended retrying Remicade, but the provider reported concerns given the long period of abstinence. The provider recommended Prometheus Anser IFX testing.  The Health Insurer has denied reimbursement for Prometheus Anser IFX testing performed on 8/19/16. Per the Health Insurer, the services at issue were investigational for the evaluation of this patient.
The anti-tumor necrosis factor agents have been noted to be associated with an increasing amount of autoantibodies resulting in an increased risk of infusion reactions, a reduced response to medications, and the need for increasing dose adjustments. Up to about 50% of patients treated with infliximab develop these antibodies, and those patients with high antibodies have been found to have a higher risk of infusion reactions. In this patients case, based on the records from 8/18/16, there was evidence of active rheumatoid arthritis and intolerance of Xeljanz.  She has tolerated Remicade in the past, with no reactions, and other anti-tumor necrosis factor agents were stopped due to ineffectiveness or cost.  There is a lack of evidence to support that Remicade would be ineffective or possibly harmful.  Remicade was stopped in the past due to cost, not medical issues. At this time, the role of this testing is still being determined. As such, the medical records and the current medical literature fail to support that Prometheus Anser IFX testing performed on 8/19/16 was 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: Experimental
Decision: Upheld

Summary Reviewer 2
A 25-year-old female has requested authorization and coverage for intravenous ceftriaxone. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found the medical evidence does not support the requested medication in this clinical setting.  This patient was diagnosed with neuroborreliosis per the submitted records. Current Lyme disease guidelines and data indicated that ceftriaxone is recommended for 14 to 21 days.  This patient has been treated with intravenous ceftriaxone for 28 days.  In addition, doxycycline has been shown to be non-inferior to ceftriaxone in some studies. Moreover, atovaquone and azithromycin are standard treatment regimens for Babesia.  For those reasons, the requested intravenous ceftriaxone is not likely to be of greater benefit than other available treatment alternatives. Based upon the information set forth above, the requested medication is 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: Upheld

Summary Reviewer 1

An 81-year-old male enrollee has requested reimbursement for Oncotype DX Prostate testing performed on 7/23/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that he National Comprehensive Cancer Network (NCCN) guidelines define the low-risk group as patients with clinical stage T1 to T2a, Grade Group 1, and serum prostate specific antigen (PSA) level less than 10 ng/mL. If the patientas life expectancy is 10 years or more, initial treatment options include: 1) active surveillance (preferred); 2) external beam radiation therapy or brachytherapy; or 3) radical prostatectomy. Molecular tumor testing can be considered for these men for prognostic information independent of NCCN risk groups. Recommendations per the NCCN guidelines support coverage post-biopsy for NCCN very-low-, low-risk, and favorable intermediate-risk prostate cancer in patients with at least 10 years life expectancy who have not received treatment for prostate cancer and are candidates for active surveillance or definitive therapy. The records indicate that this patient underwent Oncotype DX Prostate testing in 2019 as well as on 7/23/20. There is a lack of support for the services performed on 7/23/20, as Oncotype DX Prostate testing is intended for use at initial diagnosis. Therefore, Oncotype DX Prostate testing performed on 7/23/20 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 64-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma gene expression profile testing performed on 7/23/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. Therefore, DecisionDx-Melanoma gene expression profile testing performed on 7/23/18 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2 
 
A 65-year-old male enrollee has requested reimbursement for polymerase chain reaction (PCR) 
testing on 8/10/21. The Health Insurer has denied this request and reported that the service at 
issue was investigational for the evaluation of the enrollees severe diarrhea. The physician 
reviewer found that in the setting of acute diarrhea in a non-toxic, healthy patient, standard 
therapy consists of supportive care. Many of the organisms tested for, such as norovirus, cause 
self-limited disease and have no treatment. Others cause self-limited disease and can be treated 
with antibiotics, although antibiotics tend to delay clearance of the organism and may cause 
immune-mediated side effects such as hemolytic uremic syndrome. Additionally, many of the 
organisms tested for, such as entamoeba histolytica, are incredibly rare in North Americans 
eating a normal diet such that testing for them does not make sense. In this clinical setting, the 
PCR testing at issue, which involved testing for numerous gastrointestinal pathogens, was not 
likely to be more beneficial than standard testing using routine cultures for pathogens including 
E. coli subtype, or a PCR or enzyme immunoassay (EIA) test limited to determine the presence of 
Clostridioides difficile. Therefore, PCR testing on 8/10/21 was not likely to have been more 
beneficial for the evaluation of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a nine-year-old female enrollee has requested reimbursement and prospective authorization and coverage for 20 hours per week of applied behavioral analysis (ABA) therapy provided from 9/28/17 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 autism spectrum disorder.  The physician reviewer found that the request for 20 hours per week of ABA therapy provided from 9/28/17 forward was not and is not medically necessary for treatment of the patients autism spectrum disorder. According to the documentation submitted for review, the patient is documented as making progress with her goals. The Health Insurer authorized 16 hours per week of ABA therapy is medically appropriate and adequate in this clinical setting. In sum, there is a lack of clinical documentation supporting the request for 20 hours per week of direct ABA services for treatment of the patients autism spectrum disorder. Therefore, the services at issue were not and are not 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 27-year-old male enrollee has requested reimbursement for acute inpatient mental health treatment for adults provided from 4/25/16 through 6/5/16. 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 the clinical record does not support the medical necessity of service delivery at the acute inpatient level of care as of 5/20/16. On 4/24/16, the test results from the psychosis work-up had not yet returned. The patient remained guarded and isolative. He had no insight regarding his mental illness. Further, he was refusing psychotropic medication. The treatment team did provide thoughtful patient-centric care at a slow-pace to help build the rapport and trust necessary for meaningful therapeutic gains. For example, on 4/27/16, the psychologist did not confront the patients denial, rather the concepts of self-perception and idealism were introduced. As the therapeutic path was being forged, the patient continued with the diagnostic work-up. Aside from a slightly elevated cholesterol level, his laboratory studies were unremarkable. On 5/4/16, the electroencephalogram finding was normal. On 5/6/16, the neuropsychology report was published while the magnetic resonance imaging (MRI) of the brain was normal. On 5/10/16, the patient elected to start an antipsychotic medication. On 5/13/16, the patient was described as reserved and polite and noted to have no side effect from the medication. On 5/17/16, the patient was slowly feeling better. On 5/19/16, the patient agreed to step-down to a less restrictive setting and residential placement was recommended by the psychiatrist. In sum, the admission facilitated the completion of a thorough diagnostic assessment and improved the patients clinical condition. During the course of the admission, the patient had not voiced any new complaints or expressed any suicidal ideation, homicidal ideation or aggressive behavior. He was illogical at times, but neither disruptive nor disrespectful.  Based on his past behaviors and the severity of his illness, a structured and supervised setting remained indicated to consolidate the therapeutic gains, but there was no indication that residential placement would have been unsafe or inadequate as of 5/20/16.   Thus, the services at the acute inpatient level of care were medically necessary from 4/25/16 through 5/19/16, but not thereafter. Therefore, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 23-year-old female enrollee has requested authorization and coverage for FirstStep Plus Cytogenomic Constitutional (Genome-Wide) Microarray Analysis. The Health Insurer has denied this request indicating that the requested services are investigational for the evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  Chromosomal microarray testing is an appropriate first-line test for patients with non-syndromic developmental delay/intellectual disability, as well as patients with autism spectrum disorders.  There are clear management implications that chromosomal microarray testing has provided for patients.  In sum, FirstStep Plus Cytogenomic Constitutional (Genome-Wide) Microarray Analysis is likely to be of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the requested services are 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 22-year-old male with a history of idiopathic scoliosis. He has had extensive chiropractic care from 10/13/15 through 7/4/16 for at least 36 visits. His diagnoses are cervical and thoracic sprain, rib sprain, and muscle spasm. His treatment includes chiropractic manipulation, traction, and electrical stimulation, as well as abdominal and low back exercises. Overall, his condition was unchanged and his pain was consistently at 2/10. The patient has requested reimbursement for the chiropractic services provided from 6/13/16 through 8/13/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. The patient has a stable condition that shows no sign of improvement even with continuous extensive care. This is considered maintenance therapy and chiropractic is not superior to alternative forms of standard treatment. There is also no evidence that chiropractic care is useful in the treatment of idiopathic scoliosis. Therefore, the chiropractic treatments provided from 6/13/16 through 8/13/16 were not medically necessary. 

Based on the foregoing discussion, 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 53-year-old female enrollee has requested reimbursement for the Foundation One genetic testing performed on 1/25/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees serous papillary carcinoma. The physician reviewer found that the utility of the Foundation One testing has not been demonstrated to improve patient outcomes as compared to standard testing. According to the National Comprehensive Cancer Network (NCCN), to demonstrate clinical utility of panel genetic testing such as Foundation One, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. The available literature on clinical utility consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. This evidence is not sufficient to make any conclusions on clinical utility. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the Foundation One test provided on 1/25/17 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.