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

Summary Reviewer 


An 18-year-old female enrollee has requested reimbursement and prospective authorization and coverage for 52 hours per month of applied behavioral analysis (ABA) therapy provided from 10/1/15 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 review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. ABA is the standard of care for treating children with autism and the medical literature supports the treatment of autistic children with ABA therapy. Although ABA therapy is the mainstay of successful treatment of autism, its successful prolonged improvement of behavior is limited to approximately 50 percent of the patient population (Vismara and Rogers). Moreover, there is a lack of medical literature showing the effectiveness of ABA therapy applied to autistic adults. In this case, the patient has adequate language, but also has difficulty in establishing social contacts and interactions. Social skills group has been suggested to improve social competence in patients aged 6 to 21 (Reichow, et al). Therefore, based upon the medical literature cited above and the documentation submitted for review, the services at issue were not and are not medically necessary. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 50-year-old male enrollee has requested reimbursement for BCR/ABL gene rearrangement and the Tempus XT Gene Panel Testing performed on 12/17/18. 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 testing for BCR-ABL is a gene mutation particularly prominent in chronic myelogenous leukemia, for which there is a specific targeted treatment (imatinib). There has been interest in using this drug in meningioma, although the results have been equivocal at best. There is a lack of convincing data that imatinib, regardless of mutational status, is clinically beneficial in meningioma. The Tempus XT gene panel is one of many multigene panels theoretically designed to identify a gene target for therapy. Thus far, the use of such panels appears to be rarely beneficial overall. In sum, BCR-ABL gene rearrangement and the Tempus XT Gene Panel Testing performed on 12/17/18 were not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 58-year-old female enrollee has requested reimbursement and prospective authorization for Forteo 20 mcg from 1/15/16 forward.  The Health Insurer has denied this request indicating that the medication at issue was not and is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found there is sufficient support for the medication at issue in this clinical setting.  Osteoporosis is an increasingly widespread condition, and fractures are the most dangerous aspect of osteoporosis. They can lead to acute and chronic pain as well as increased mortality.  Until recently, pharmacological options for the treatment of osteoporosis have been limited to anti-resorptive agents, including bisphosphonates.  Newer treatment agents have become available over the past few years, including teriparatide (Forteo).  Forteo is a recombinant form of the biologically active component of parathyroid hormone which has been shown to increase bone mass and prevent fractures in osteoporotic bone.  In contrast to anti-resorptive agents, such as bisphosphonates and Prolia, recent data also demonstrates that Forteo may aid in the healing of fractures and non-unions in osteoporotic patients.  Therefore, Forteo 20 mcg from 1/15/16 forward was and is medically indicated for the treatment of this patient.  Therefore, the medication at issue was and 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 62-year-old male enrollee has requested reimbursement for hyaluronan injections in the knee performed on 12/13/17, 12/18/17, 12/27/17, 1/05/18 and 1/12/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees osteoarthritis. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient presented on 12/01/17 for follow-up regarding his left knee. It was noted that there was MRI evidence of tricompartmental osteoarthritis, most severe in the patellofemoral joint and a mild joint effusion. A left knee examination is not documented in the submitted medical records, and functional limitations are not discussed. Detailed evidence of a recent, reasonable and/or comprehensive nonoperative treatment protocol trial, including nonsteroidal anti-inflammatory drugs, exercise, and corticosteroid injections, and failure has not been submitted. There is evidence-based medical literature support for the use of hyaluronan acid (Supartz) injections in the treatment of significantly symptomatic osteoarthritis of the knee, when conservative treatment has failed. However, in this case, there is no clinical evidence documented to support a diagnosis of severe osteoarthritis or functional limitations discussed. Therefore, hyaluronan injections in the knee performed on 12/13/17, 12/18/17, 12/27/17, 1/05/18 and 1/12/18 were not medically necessary for the treatment of this patient. 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 30-year-old male enrollee has requested reimbursement for L0637 (lumbar support brace) provided on 1/7/15. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees low back pain. The physician reviewer found that based on the clinical records submitted for review, the L0637 (lumbar support brace) provided on 1/7/15 was not medically necessary for treatment of the patients medical condition. The office visit dated 1/7/15 does not provide sufficient rationale supporting the clinical indication for the lumbar support brace provided. On 1/7/16, the office visit indicates that the patient reports to improving 10% since the onset. Given that the patient had improved and in the absence of clinical rationale supporting the device, the L0637 (lumbar support brace) provided on 1/7/15 was not medically necessary for treatment of the patients medical condition. Therefore, the device at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 79-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant. 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 the patient has paroxysmal atrial fibrillation. He requires anticoagulation therapy for life and has been maintained on Eliquis therapy. He has a high-risk occupation for trauma and is on job sites daily by report. The Watchman atrial appendage occluder device has been approved by the U.S. Food and Drug Administration (FDA) for this indication and is recommended for consideration in patients with either an absolute or relative contraindication to long-term anticoagulation. It is not considered an investigational device in these clinical situations. This patient has a relative contraindication to anticoagulation and is a good candidate for Watchman. Therefore, percutaneous transcatheter closure of the left atrial appendage with endocardial implant is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 60-year-old male enrollee has requested reimbursement for St. Jude Nanostim Leadless Pacemaker implant provided on 6/24/15. The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found the services at issue were not likely to be more effective for this patient than other available options. Leadless pacemakers are currently considered controversial and there is a lack of documented contraindications to placement of a traditional endocardial lead. Studies in the peer-reviewed literature suggest that long term complications remain to be determined (Reddy, et al; Miller, et al). All told, the St. Jude Nanostim Leadless Pacemaker implant provided on 6/24/15 has not been established as 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 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: Upheld

Summary Reviewer 3

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 there currently are three major approaches to the management of localized prostate cancer. These include surgery, forms of radiation therapy, or active surveillance, with no specific anti-cancer treatment given. Treatment recommendations are made as to these options based on risk stratification, which will estimate the risk of the future development of progressive cancer. The individualas situation is evaluated, incorporating clinical factors, as well as PSA and the details of the prostate biopsy. By such methodology, the patient is placed into a risk category, ranging from very low risk, to low risk, to intermediate risk, to high risk.
A further refinement of prognostication is the use of genomic panels, such as Oncotype. This is a 17-gene panel which seems capable of predicting recurrence after treatment for prostate cancer. NCCN guidelines suggest it may be useful in decision making in the low to intermediate risk category in the initial assessment of the cancer and its treatment. In this case, Oncotype DX Prostate testing was performed after this patientas 2019 biopsy. Despite being placed into the intermediate risk category, he elected active surveillance only. Although there was minimal to no change in his clinical status in his repeat biopsy, he was considering specific treatment. In this setting, repeat Oncotype DX Prostate testing was not likely to have added to the clinical decision making, as he already had a concerning Oncotype assay in 2019. NCCN guidelines do not support the services at issue in this setting. 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: Experimental
Decision: Overturned

Summary Reviewer 1 
 
A 49-year-old female enrollee has requested reimbursement for polymerase 
chain reaction (PCR) testing performed on 4/29/19. 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 there is sufficient support for the 
services at issue in this clinical setting. Patients with vaginitis can 
be evaluated and treated with an examination, microscopy and/or cultures 
depending on the patients symptoms and findings. The exact process 
depends on the provider and the resources available at that particular 
office. This patient reported persistent odor for one month. No discharge 
was noted on examination, and nitrazine was noted to negative. 
 be 
Evaluation with PCR testing was consistent with standard of care in this 
setting. Therefore, PCR testing performed on 4/29/19 was likely to have 
been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 54-year-old male enrollee has requested reimbursement for the Prometheus diagnostic panel performed on 11/24/15. 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 Prometheus diagnostic panel performed on 11/24/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient presented with an acute undiagnosed infection with negative stool studies. To acquire objective data to provide effective treatment management for this patient the use of the diagnostic panel was indicated. The Prometheus diagnostic panel combines serologic, genetic, and inflammatory markers to help differentiate IBD from non-IBD. The testing at issue was indicated to evaluate whether his symptoms were predictive of IBD or another cause of colitis. Therefore, the testing at issue has been established as 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 1


A 41-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 4/02/15. 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 the current medical evidence does not support the services at issue in this clinical setting.  The records do not demonstrate the clinical rationale for this testing.  The patient has been exposed to other biologics in the same class.  Anser IFX testing is not standard of care in this clinical setting.  All told, Anser IFX testing performed on 4/02/15 was not 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 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 residential treatment center services provided from 5/30/16 through 6/30/16. 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 that the residential treatment center services provided from 5/30/16 through 6/30/16 were not medically necessary for treatment of the patients medical condition. On admission the patient was not in withdrawals. There was no evidence of post-acute withdrawal symptoms. He was not a danger to self or others. Both his medical and psychiatric conditions could have been treated on an outpatient basis. He was not psychotic or manic.  There were no emotional, behavioral, cognitive, or impulsive symptoms to justify residential level of care. He presented for admission with ambivalence, and while in treatment developed a responsible drinking plan. The goal of treatment is abstinence with ongoing vigilance to prevent relapse. In this case, the patient could have been treated at a lower level of care such as intensive outpatient program (IOP) or outpatient with a concurrent 12-step program, and continuation with his psychotherapist. As such, 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 56-year-old female enrollee has requested reimbursement for the Foundation One genetic testing provided on 1/12/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees recurrent ovarian cancer.  The physician reviewer found that molecular profiling is an assay of an individual patients cancer cells to detect specific genomic or molecular abnormalities that might serve as a target for a potential treatment. There are multiple non-randomized clinical trials exploring the value of molecular profiling. However, there is a lack of data from these trials demonstrating improved health outcomes based on the findings in these assays (Von Hoff, et al). Currently, there is a paucity of scientific data suggesting that the Foundation One genetic testing performed on 1/12/15 was likely to have been more beneficial for evaluation of this patients medical condition than standard available testing. Based upon the information set forth above, I have determined 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 3

A 58-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 1/03/17 and transfer of the laboratory specimen. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that 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 to 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 been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, the superior effectiveness of DecisionDx-Melanoma testing performed on 1/03/17 and transfer of the laboratory specimen has not been established in this patients case. 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


The patient is a 63-year-old male who presents with recurrent sinusitis with symptoms of rhinorrhea, nasal congestion, nasal discharge and facial pain. The patients prior medical history is also significant for moderate persistent asthma, allergic rhinitis, gastroesophageal reflux disease (GERD), hypertension, and deviated septum/polyps. The patient also with reported history of asthma with complaints of cough and wheezing. The patients has been treated with ProAir HFA, Flonase, fluoxetine, intranasal saline, and Losartan. The patient has requested authorization and coverage for Dulera 100 mcg/5 mcg inhaler. The Health Insurer has denied this request indicating that the requested medication is not medically necessary. There was no documentation provided in terms of spirometry, bronchodilator response or bronchoprovocation testing that this patient has a confirmed diagnosis of asthma. In addition, no records were provided on the patients current symptoms or longevity of disease. Furthermore, there is no documentation that the patient has failed treatment with other inhaled corticosteroid/long-acting B2-agonist (ICS/LABA) medications such as Advair, Breo, Symbicort, or generic fluticasone/salmeterol, which are on the Health Insurers formulary. Given these findings, the requested Dulera 100 mcg/5 mcg inhaler is not supported as medically necessary for treatment of this patients medical condition.  Based on the foregoing discussion, the requested medication is 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 parent of an 11-year-old male enrollee has requested reimbursement for the FirstStepDx PLUS test provided on 7/6/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees attention deficit hyperactivity disorder (ADHD). The physician reviewer found that array-based comparative genomic hybridization, also known as chromosomal microarray (CMA) has become standard of care to evaluate children with developmental delay, intellectual disability, autism spectrum disorders or congenital anomalies. The yield of this test is 8-17% and varies with the degree of cognitive impairment, the presence of dysmorphic features, and the presence of congenital anomalies. The patients presentation meets the criteria established for microarray use with autism spectrum disorder and a congenital anomaly. In addition, the patients positive family history provides additional support for testing (Baris, et al; Johnson, et al). Henderson and colleagues demonstrated that approximately 12.7% of patients meeting referral criteria had a pathogenic copy number variant identified on microarray, and that half of those results influenced management. Riggs and colleagues found that 7% of microarray results impact clinical management, a rate which is similar to other genetic tests. Data have now emerged showing that actionable findings from chromosomal microarray justify its use. Thus, the FirstStepDx PLUS test provided on 7/6/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the 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.