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

Summary Reviewer 1


A 57-year-old male enrollee has requested reimbursement for Oncotype DX testing Prostate Cancer Assay provided on 9/15/15. The Health Plan has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees elevated prostate specific antigen (PSA). The physician reviewer found THE testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the testing at issue in this clinical setting. Several tissue-based molecular assays have been developed in an effort to improve decision-making in newly diagnosed patients considering active surveillance and in treated men considering adjuvant therapy or treatment for recurrence. Patients with clinically localized disease may consider the use of tumor-based molecular assays. Retrospective case cohort studies have shown that molecular assays performed on biopsy or prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network (NCCN) risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy, and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. In this case, the patient has low-risk localized prostate cancer and the testing at issue was indicated to assist with improve decision-making. All told, the Oncotype DX testing provided on 9/15/15 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: Upheld

Summary Reviewer 3


A 53-year-old female has requested reimbursement for advanced lipoprotein testing.  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 the current guidelines do not recommend routine use of advanced lipoprotein tests, mainly because it is unclear how much incremental prognostic information is provided by these tests beyond that available from a standard lipid panel.  To date, the most useful measures obtained from lipoprotein tests relate to atherogenic particle number.  However, at this time, non-high-density lipoprotein (HDL) cholesterol or the total/HDL cholesterol ratio is of comparable predictive strength.  Low-density lipoprotein (LDL) sub-fractions measurement may provide some information regarding risk, but whether this is incremental beyond the current standard of care is unclear.  In this patients case, she was already on statin therapy for elevated cholesterol.  As such, and given the other known baseline coronary risk factors (hypertension, hyperlipidemia, prediabetes), there is no additional diagnostic or prognostic information to be gleaned by the testing at issue.  Thus, advanced lipoprotein testing performed on 3/15/16 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 60-year-old male enrollee has requested reimbursement for chiropractic services including CPT codes 97110, 97032, 97140 and 99214 provided on 6/1/17, 6/8/17, 6/15/17, 8/14/17, and 9/7/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees spondylosis without myelopathy/radiculopathy of the cervical region. The physician reviewer found that the provided documentation does not establish the medical necessity of the chiropractic services provided from 6/1/17 through 9/7/17. Specifically, the records do not objectively verify functional improvements with prior chiropractic therapy over eight weeks of care. As noted in the current medical literature and guidelines, the documentation should report objective functional improvement with chiropractic treatment to support an indication for future services. Accordingly, the chiropractic services including CPT codes 97110, 97032, 97140 and 99214 provided on 6/1/17, 6/8/17, 6/15/17, 8/14/17, and 9/7/17 were not medically necessary for treatment of this patients neck pain and low back pain. 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: Upheld

Summary Reviewer 3

The patient is a 36-year-old female with abnormal uterine bleeding. She reported heavy menstrual cycles with cramping affecting her quality of life. She tried hormonal options for medical management with birth control pills in November 2016, but experienced headaches. A pelvic ultrasound was performed showing no intracavitary abnormalities.  On 12/30/16, endometrial ablation was performed. The Health Insurer has denied reimbursement for the services at issue. Per the Health Insurer, endometrial ablation was investigational for the treatment of this patient. The medical evidence does not support the services at issue in this clinical setting. An endometrial ablation is a minimally invasive technique used to destroy the uterine lining for the treatment of chronic menorrhagia/abnormal uterine bleeding. This technique is supported by peer-reviewed current medical literature in patients who no longer desire fertility and in whom a thorough work-up has been performed to rule out other causes of abnormal uterine bleeding. This evaluation includes performing a pelvic ultrasound and an endometrial biopsy or dilation and curettage (D&C).  Furthermore, the patient should have tried and failed medical management options over a reasonable period of time. Alternative treatment options, including hormones (pills, intrauterine device) and surgery, should be discussed and documented in the medical records. In this patients case, there was a lack of clinical documentation regarding the duration of her symptoms. The patient no longer desired fertility. She trialed a course of hormonal management with oral contraceptives, although, the overall duration of this treatment and failure is not clearly documented. Additionally, there is no documentation to support an evaluation of her endometrial lining to rule out endometrial hyperplasia or malignancy by biopsy or D&C.  Finally, there is no clinical documentation to support a discussion of all her options prior to proceeding with endometrial ablation. Thus, endometrial ablation performed on 12/30/16 was not likely to have been more efficacious than other available treatment options. Based upon the information set forth above, 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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 48-year-old female enrollee has requested reimbursement for Oncotype DX Colon Cancer Assay performed on 4/28/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found the medical evidence shows that adjuvant chemotherapy confers a survival advantage for patients with stage III colorectal cancer, but not for those with stage II disease.  Meta-analyses have not shown any survival advantage for 5-FU/leucovorin treatment in stage II patients.  The reasons for this conclusion are complex.  Stage II patients do well after surgery alone, so that the magnitude of the survival benefit conferred by adjuvant chemotherapy is small.  Additionally, randomized clinical trials to date have had too few stage II patients to discern a statistically significant advantage.  In contrast, the benefit for stage III patients is quite significant, and it is likely that stage II patients benefit as well. Therefore, subset analyses to identify those patients with prognostic features that may predict for chemotherapy benefit have been analyzed.  For example, oncologists consider adjuvant treatment for those stage II patients with T4 disease, obstructing lesions, and other biomarkers.  The Oncotype DX Colon Cancer Assay uses a reverse transcriptase-polymerase chain reaction assay for 12 genes in an algorithm that can be used to predict recurrence.  The medical evidence for the test is sufficient to allow its use to estimate the risk of recurrence for stage II patients when incorporated with other tests, such as standard pathology and microsatellite instability testing.  Thus, Oncotype DX Colon Cancer Assay performed on 4/28/16 was likely to have been more effective 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: Medical Necessity
Decision: Overturned

SummaryA 54-year-old female enrollee has requested authorization and coverage for spine surgeries. The Health Insurer has denied this request indicating that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. This patient presents with severe neck pain radiating into the right upper extremity with numbness, tingling and weakness. Functional limitations are documented in activities of daily living. Clinical examination findings have evidenced positive Spurlings test, motor and sensory deficits, and reflex changes consistent with imaging evidence of central canal stenosis at C5-6 (6.1 mm) and C6-7 (7.3 mm), with reported cord compression at C5-6 and C6 nerve root compromise. There was radiographic evidence of disc space narrowing at C5-6 and C6-7 with anterior spurring at C5-6 and C6-7. Evidence of a recent nonoperative treatment protocol trial and failure has been submitted. She currently presents with progressive neurologic complaints, including right hand numbness, positive Hoffmans examination, upgoing toes, broad-based gait, and hyperreflexia of the bilateral lower extremities, right greater than left. Under consideration is a request for anterior cervical discectomy and fusion at C5-6 and C6-7. Based on clinical and imaging findings, there is likely contribution to the symptomatic condition from both levels requested. There is sufficient support for the requested services in this clinical setting. Therefore, the requested spine surgeries are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 56-year-old male enrollee has requested reimbursement for genetic testing performed on 2/28/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that as a standard of care, metastatic colon cancers should be tested for KRAS, NRAS, BRAF, HER2, and microsatellite instability or mismatch repair (MMR) testing. Per the National Comprehensive Cancer Network (NCCN) guidelines, these can be done individually or as part of next-generation sequencing. Next-generation sequencing panels have the ability to pick up rare and actionable mutations and fusions. Universal genetic testing is recommended on all colon cancer tumors, and next-generation sequencing allows for initial screening with microsatellite instability testing. Next-generation sequencing offers the advantage of identifying markers known to have targeted therapy as well as potential clinical trials. FoundationOne is one available test that offers this. The medical evidence supports the services at issue in this clinical setting. Therefore, genetic testing performed on 2/28/18 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

The patient is a 43-year-old female with a history of major depressive disorder, chronic pain and insomnia. The patient has failed multiple medications for the treatment of her depression. The patient has also failed transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT). The patient had a suicide attempt in 2016 after an overdose on her narcotics. This caused a hypoxic brain injury. The patient has requested authorization and coverage for CPT 64568 (implantation of vagus nerve neurostimulator electrode). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient.  This patient has had an extensive treatment history for her depression, including medications, TMS and ECT. However, there was no mention of her psychotherapy history to address her childhood trauma. There was no mention of psychotherapy to help manage her chronic pain. The medical literature has mixed results about the efficacy of the effectiveness of vagus nerve stimulation for treatment-resistant depression. Evidenced-based therapy such as cognitive processing therapy, prolonged exposure therapy, and intensive psychodynamic therapy along with pain management therapy could be utilized to help with the treatment of this patient. Therefore, the requested CPT 64568 (implantation of vagus nerve neurostimulator electrode) is not likely to be of greater benefit than other treatment options. 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 33-year-old male enrollee has requested authorization and coverage for CPT code 27299 (unlisted procedure, pelvis/hip joint). The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees hip pain. The physician reviewer found that surgical hip dislocation is an established technique for addressing both articular and periarticular pathology associated with painful femoral acetabular impingement. This patient has extensive labral tearing and degeneration including posterior which would be difficult or impossible to treat arthroscopically. Periacetabular osteotomy and labral repair cannot be performed open without dislocating the hip. Thus, dislocation of the femoral head is necessary to access and treat the acetabular sided pathology. Given these findings, the requested CPT code 27299 (unlisted procedure, pelvis/hip joint) is supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested procedure is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 55-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees severe persistent asthma. The physician reviewer found that currently, the three initial trials of bronchial thermoplasty have demonstrated improved symptom control in well selected patients after the procedure was completed. Cox and colleagues reported on 112 patients with moderate to severe asthma and demonstrated improved control over the course of the one-year follow-up. Similarly, Pavord and colleagues found short-term worsening in symptoms, but evidence of improved long-term control of asthma. Castro and colleagues compared thermoplasty with a sham procedure and followed the patients for 12 months. The authors found that the thermoplasty group had fewer exacerbations and improved quality of life when compared to the sham group. However, this patients records do not indicate that she is likely to benefit from bronchial thermoplasty. The providers notes allude to a diagnosis of severe persistent asthma and normal pulmonary function testing (PFT). While PFT results may be unremarkable in patients with asthma, once the disease is persistent, the PFT results are often abnormal. Further, this patient is on medications for several illnesses which may mimic asthma, specifically reflux and sinus disease. Lastly, given the normal PFT findings, lack of clear asthma triggers along with persistent symptoms and chronic steroids, vocal cord dysfunction has not been ruled out, which is often confused for asthma and does not respond to bronchodilators, steroids or bronchial thermoplasty. All told, the requested bronchial thermoplasty is not supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 54-year-old female enrollee has requested reimbursement for the shingles vaccine performed on 2/06/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of rheumatoid arthritis. The physician reviewer found the varicella-zoster virus causes two clinically distinct forms of infection.  Herpes zoster is related to reactivation of varicella-zoster virus infection and is characterized by a painful, unilateral vesicular eruption in a dermatomal distribution. The herpes zoster vaccination can decrease the risk of developing herpes zoster and post-herpetic neuralgia associated with infection.  The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of all patients 60 years of age or older, including patients who report a previous episode of zoster and patients with chronic medical conditions (such as chronic renal failure, diabetes mellitus, rheumatoid arthritis, chronic pulmonary disease), unless those conditions are contraindications. In clinical practice, the vaccine is recommended for patients between 50 and 59 who are receiving low-level immunosuppressive therapy or are expected to receive high-level immunosuppressive therapy or for patients that would have difficulty tolerating a zoster infection. In this case, the patient has multiple skin conditions including lichen planus, herpes simplex virus, and atopy, and she has been diagnosed with rheumatoid arthritis. Rheumatoid arthritis is treated with immunosuppressive medications that would leave the patient vulnerable to infections. Given this patients rheumatoid arthritis and skin conditions, it was appropriate to vaccinate this patient. Therefore, the shingles vaccine performed on 2/06/17 was likely to have been of greater benefit 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: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The patient is a 63-year-old male with a history of high-risk prostate cancer. A hydrogel spacer 
was recommended as well. The Health Insurer has denied the requested services as not medically 
necessary for treatment of the insureds medical condition. The physician reviewer found that, 
overall, the utilization of proton beam therapy is not recommended for routine use in the 
treatment  of  patients  with  prostate  cancer.  Proton  beam  therapy  has  unique  properties 
compared to standard photon beam therapy in its ability to deposit radiation dose and can 
potentially result in fewer areas of low scattered radiation dose. Proton beam therapy is currently 
utilized and most strongly indicated in settings where severe toxicities would result if normal 
tissue constraints cannot be met by photon beam. However, in the treatment of patients with 
prostate cancer, studies have failed to show that the use of proton beam therapy results in a 
demonstrable, clinically significant difference in overall survival, quality of life, or reduction of 
high-grade toxicities over photon beam therapy (Royce and Efstathiou). Proton beam therapy 
may be efficacious in the treatment of patients with prostate cancer in cases of unusual anatomy 
or in cases of re-irradiation of adjacent tissues. Volumetric modulated arc therapy (VMAT) is a 
standard photon therapy radiation technique that is frequently utilized to achieve clinically 
equivalent normal organ dose constraints as proton beam therapy (Schroeck, et al.; Nogueira, et 
al.). Excellent dose toxicity outcomes have been demonstrated for standard VMAT in locally 
advanced prostate cancer. In this case, the records provided for review indicate that this patient 
has high-risk prostate cancer, but there is a lack of documentation indicating that the patient had 
unusual anatomy or re-irradiation of adjacent tissues. Therefore, the requested proton beam 
therapy is not medically necessary for treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 62-year-old female enrollee has requested reimbursement for ChemoFX assay performed on 5/08/15. 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 Chemosensitivity testing, such as ChemoFx, is not considered a standard of care and is not recommended by current guidelines.  In vitro assays of chemosensitivity or resistance, such as the ChemoFx assay, have been developed as a method to select the optimal chemotherapy regimen or identify those agents least likely to be effective.  However, the utility of these assays have not been prospectively validated.  Therefore, ChemoFx assay performed on 5/08/15 was not likely to have been more efficacious 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.