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

Summary Reviewer 3

A 51-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 7/13/15.  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 Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor. In this case, the patient presented with heterogeneously dense breast tissue. The ability to separate out superimposed tissue enables the possible delineation of an occult mass. In addition, the presence of asymmetry is also an indication for tomosynthesis. For this patient, tomosynthesis was utilized as a problem solving tool. Therefore, the breast tomosynthesis performed on 7/13/15 were 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 59-year-old male enrollee has requested authorization and coverage for Orthovisc series (J7324 x 4). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees knee pain. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested services. The peer-reviewed literature supports the use of hyaluronic acid injections, such as Orthovisc, for the treatment of knee osteoarthritis and indicates that these injections provide a longer lasting benefit than intra-articular corticosteroid injections. Given that the patients provider has advised against the use of intra-articular corticosteroid injections due to his hypertension, proceeding with corticosteroid injections would not be warranted or consistent with peer-reviewed literature. Therefore, the requested Orthovisc series x 4 is medically necessary for the treatment of the patients medical condition. For the reasons provided, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 66-year-old female enrollee has requested authorization and coverage for gene testing provided on 12/28/15. 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 medical evidence does not support the superior efficacy of the services at issue in this clinical setting. The medical evidence shows that survival rates for melanoma vary based on the depth of invasion of the primary tumor. Based on the medical record provided the patients stage was a T3, and as such, a stage II. Stage II has an increased risk of recurrence. Multiple analyses have demonstrated that survival/prognosis is dependent upon tumor thickness, age at diagnosis, location of primary, presence of ulceration, mitotic rate, lymph node involvement, and growth pattern. Genomic and proteomic expression profiling has been under investigation, but the role in standard therapy has not been clearly outlined. DecisionDX melanoma is a commercial gene expression profile test which has been developed for patients with local (stage I and II) or locoregional (stage III) cutaneous melanoma. The most recent assessment was to determine the impact on clinical practice and therefore did not or was not able to discuss the impact on patient outcome. The National Comprehensive Cancer Network (NCCN) guidelines indicate that for stage II melanoma, wide excision be pursued with sentinel lymph node evaluation if the tumor is greater than 0.75 mm in thickness. For stage IIA, clinical trial or observation is recommended whereas for stage IIB or IIC, in addition to those options, interferon alpha should also be considered. There are no current recommendations to undergo genomic or proteomic analysis to assess risk or assess benefit of adjuvant therapy.  Based on the review of the current guidelines, it is unclear that the addition DecisionDX melanoma improved this patients overall care plan since the role in clinical care is still undergoing investigation. In sum, the gene test performed on 12/28/15 was not likely to have been superior to the available options in 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 63-year-old male enrollee has requested reimbursement for an unlisted chemistry procedure performed on 7/27/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees malignant melanoma. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add to these statistics. By Balch staging, this melanoma would be classified as a T1a, or stage 1A. As such, this patient would be expected to have at least an 88% ten-year survival. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either Class I (90 to 92% five-year recurrence-free survival), or Class II (48 to 77% five-year recurrence-free survival). Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients undergoing sentinel node sampling. Berger and colleagues reported on 156 cases, but there was not sufficient follow-up to determine the actual value of the test. It is not clear how the five-year DecisionDx-Melanoma data compares to the Balch ten-year data. Most importantly, it is unproven as to whether the DecisionDx-Melanoma classification can be used to make clinical decisions, especially in patients with stage 1A disease. The current medical evidence does not support the services at issue in this clinical setting. All told, unlisted chemistry procedure performed on 7/27/17 was not medically necessary for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 62-year-old male enrollee has requested reimbursement for testing for liver disease provided on 6/11/19. 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 in chronic hepatitis B patients, such as this patient, identification of cirrhosis defines treatment endpoints and options. Non-invasive studies, such as FibroTest, are typically applicable to the hepatitis C population, and those with other chronic liver conditions. Relative to FibroTest itself, Jieanu and colleagues opined Fibrotest is a patented formula which involves several parameters: total bilirubin, haptoglobin, gamma glutamyl transpeptidase, a2-microglobulin apolipoprotein-A, age and gender, with the results correlated with the METAVIR score. This evaluation is the most used indirect marker showing excellent results in a meta-analysis in chronic hepatitis C (CHC).  Supporting this contention, Parikh and colleagues concluded that FibroTest is useful in ruling out chronic hepatitis B-related cirrhosis. Thus, while liver biopsy remains the gold standard for assessment of hepatic fibrosis, the assay under review in this case provides ready assessment of progression to cirrhosis without the inherent risks of invasive testing. In sum, testing for liver disease (FibroTest-ActiTest/HCV-FibroSure) provided on 6/11/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 55-year-old female enrollee has requested authorization and coverage for botulinum toxin type A (Botox) treatment and ongoing treatment. 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 that review of the submitted documentation and relevant literature supports the use of Botox injections in this clinical setting. According to the literature review by Szok and colleagues Recent clinical studies revealed that onabotulinumtoxinA was an efficacious and safe treatment for chronic migraine. The documentation submitted for review documents the patient is diagnosed with chronic migraine headaches with at least 14 headache days per month. This patient has tried other prophylactic measures without success. In addition, Botox is U.S. Food and Drug Administration (FDA) approved for the treatment of chronic migraine. For the reasons provided, the request for Botox injections and ongoing treatment are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. 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: Upheld

Summary Reviewer 2


A 45-year-old male enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees asthma. The physician reviewer found there is sufficient medical support for the requested procedure in this patients case.  Clinical data demonstrates the short and long term benefits of bronchial thermoplasty for patients with severe asthma. The three initial trials of bronchial thermoplasty have demonstrated improved symptom control after the procedure was completed. Per the submitted records, this patient is unable to tolerate steroids (inhaled or otherwise). Also, the patient has undergone the evaluation and management of several alternative diagnoses (allergic disease, vocal cord dysfunction and reflux). Given the patients inability to tolerate an ideal medication regimen for his asthma, bronchial thermoplasty is an effective intervention. Thus, the requested procedure is an appropriate next step in management and treatment of the patients symptoms. As such, bronchial thermoplasty is likely to be superior over any available standard therapy for treatment of the patients medical condition. Based upon the information set forth above, the requested procedure is 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 2

A 63-year-old female enrollee has requested reimbursement for FoundationOne CDx testing performed on 11/27/20. 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 the use of next generation sequencing or molecular profiling is recommended by the National Comprehensive Cancer Network guidelines for patients with endometrial cancer. To date, molecular analysis of endometrial carcinoma has identified four clinically significant molecular subgroups with differing clinical prognoses: POLE mutations, microsatellite instability-high (MSI-H), copy number low, and copy number high. Ancillary studies for POLE mutations, mismatch repair (MMR)/MSI, and aberrant p53 expression are encouraged to complement morphologic assessment of histologic tumor type. Molecular analysis can help classify difficult cases and provide future therapeutic targets. Molecular targets can help distinguish the patientas eligibility for immunotherapy. Next generation sequencing such as with FoundationOne CDx can help identify therapeutic options both on and off of clinical trials and is a standard of care for patients with advanced endometrial cancer. Therefore, FoundationOne CDx testing performed on 11/27/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1 
 
A 40-year-old male enrollee has requested reimbursement for nasopharyngoscopy, surgical, with 
dilation of eustachian tube (i.e. balloon dilation); bilateral, on 8/26/21. The Health Insurer has 
denied this request and reported that the service at issue was investigational for the treatment of 
the enrollees bilateral eustachian tube dysfunction. The physician reviewer found that that balloon 
dilation of the eustachian tube is supported in current medical literature and has been accepted as 
a  standard  therapy  in  the  otolaryngology  community.  Tucci  and  colleagues  report  that  the 
American Academy of Otolaryngology  Head and Neck Surgery (AAO-HNSF) reports that 
balloon dilation of the eustachian tube is an option for the treatment of patients with obstructive 
eustachian tube dysfunction that is supported by multiple peer-reviewed studies. In a prospective, 
multicenter, randomized controlled trial, Meyer and colleagues showed that eustachian tube 
balloon dilation is a safe and effective treatment for persistent eustachian tube dysfunction based 
on improved 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) scores. The authors 
concluded,  Balloon  dilation  is  superior  to  continued  medical  management  for  persistent 
eustachian tube dysfunction. In a prospective, multicenter, randomized, controlled trial, Poe and 
colleagues concluded, This study demonstrated superiority of balloon dilation of the eustachian 
tube with balloon catheter and medical management compared to medical management alone to 
treat Eustachian tube dilatory dysfunction in adults. Regarding the long-term efficacy of balloon 
dilation for treating patients with persistent Eustachian tube dysfunction, Cutler and colleagues 
reported that balloon dilation results in durable improvements in symptoms and middle ear 
assessments for patients with persistent eustachian tube dysfunction at mean follow-up of longer 
than two years. In this case, the patient has eustachian tube dysfunction and had failed PE tube 
placement and medical therapy. Repeat PE tube placement was complicated by a history of 
difficult in-office PE tube placement due to pain and syncope. In this clinical setting, the service 
at issue was likely to have been more beneficial than standard therapy with continued medical 
management.  Therefore,  nasopharyngoscopy,  surgical,  with  dilation  of  eustachian  tube  (i.e. 
balloon dilation); bilateral, on 8/26/21, was likely to have been more beneficial for treatment of 
the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 60-year-old female enrollee has requested reimbursement for Prolia (denosumab) injection administered on 10/20/15. The Health Insurer has denied this request indicating that the medication at issue is considered investigational for treatment of the enrollees osteoporosis. The physician reviewer found Prolia is approved by the Federal Drug and Administration for treatment of postmenopausal osteoporosis. It is anticipated that Atelvia will not provide the benefit of therapy given that the patient has poor absorption and her bone density has not improved in the hip. The patient has severe osteoporosis as documented by a BMD below -3 in both femoral necks and prior peripheral fracture. The patients medical records indicate that she is at a high risk for fracture and studies have shown that Prolia reduces the incidence of vertebral fractures by about 68%, hip fractures by about 40%, and nonvertebral fractures by about 20% over 3 years (Cosman et al). Moreover, the patient was on bisphosphonate (Atelvia) therapy and her BMD did not improve. The patient also has a history of gluten intolerance, which suggests that she might have a malabsorption factor, which makes oral bisphosphonates poorly absorbed and therefore ineffective. For all these reasons, the medication at issue was likely to be of more benefit for treatment of the patients osteoporosis than available standard therapy. Based upon the information set forth above, the medication at issue was 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 28-year-old female enrollee has requested reimbursement for substance use residential treatment center services provided from 1/23/17 through 2/10/17. The Health Plan 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 substance use residential treatment center services provided from 1/23/17 through 2/10/17 were not medically necessary for treatment of the patients medical condition. Due to the lengthy history of substance use, a residentially based detoxification and preliminary introduction to chemical dependency treatment was safe, appropriate and consistent with good medical practice. Although addiction specialty services remained indicated, the clinical documentation does not demonstrate the medical necessity of treatment in a 24-hour supervised setting as of 1/23/17. By 1/22/17, the patient embraced recovery principles and was both active in treatment and motivated for sobriety. She was not experiencing withdrawal, or significant medical or psychiatric symptoms. She had a supportive family and a safe home environment. She had no prior history of chemical dependency treatment in a less restrictive setting such as anti-craving medication, community programming, outpatient specialty care, intensive outpatient services or partial hospitalization. In sum, there is a lack of evidence to suggest that comprehensive, evidence-based services provided in a less restrictive treatment setting would have been insufficient. Thus, the services at issue were 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: Upheld

Summary Reviewer 3


A 48-year-old male enrollee has requested reimbursement for polymerase chain reaction (PCR) testing performed on 7/15/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient had negative serological testing. PCR testing is not the standard of care in making a diagnosis of Lyme disease. Testing can be effectively used on synovial fluid in cases of suspected Lyme arthritis and on cerebrospinal fluid (CSF) when there is suspicion of neurologic Lyme disease. In sum, PCR testing is not indicated unless there is clear serological evidence of Borrelia infection, which was not present in this case. Therefore, the PCR testing performed on 7/15/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a five-year-old male enrollee has requested authorization and coverage for the SleepSafe bed with bedding. The Health Insurer has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation supports the requested equipment in this clinical setting.  The records indicate that the patient no longer fits in his current crib, and he as at a high risk of fall.  The medical records document the need for the requested SleepSafe bed in this clinical setting.  It is medically indicated for the patient to have medical equipment designed to improve personal safety.  All told, the requested SleepSafe bed with high rails and padded bumpers is medically indicated for the treatment of this patient.  Therefore, the requested equipment is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

The parent of a 14-year-old female enrollee has requested reimbursement for subtalar arthroereisis provided on 12/11/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral moderate-to-severe pes planus. The physician reviewer found that based on the current medical literature, it was not likely to be more beneficial for this patient to have undergone subtalar arthroereisis for treatment of bilateral flexible flatfoot than treatment with standard available options. There are as many as eight different implants that are utilized to correct valgus deformity that are inserted into the sinus tarsi. The use of sinus tarsi implants or subtalar arthrodesis as an alternative to Evans procedure is not well supported with a high incidence of failure of the implants to maintain correction, recurrence of pain and the need to remove the implants and convert to a more durable solution. In spite of the reported short-term positive benefit, the lack of durability in the prosthesis is reported in a number of studies with high rates of need for revision. The support in the literature for arthroereisis is in the form of case series studies, and the level of the support in the literature is weak. Consistent with these findings, the subtalar arthroereisis provided on 12/11/14 was not likely to have provided this patient with an improved health outcome beyond that expected with standard interventions. Based upon the information set forth above, I have determined the services at issue were 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.