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

Summary Reviewer 3

A 31-year-old female enrollee has requested reimbursement for the collagen cross links, any method (CPT code 82523) provided on 1/10/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees left ankle pain status De Novo procedure for osteochondral lesion of the medial talar dome. The physician reviewer found that measurement of serum or urinary collagen crosslinks or other biochemical markers of bone remodeling has not been demonstrated in well designed randomized controlled clinical trials to improve the screening, diagnosis, or management of clinical conditions concerning bone healing and bone turnover. Overall, there is a paucity of data that the clinical value of these markers results in improved health outcomes. Given these findings, the collagen cross links, any method (CPT code 82523) provided on 1/10/17 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 service 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: Experimental
Decision: Overturned

Summary Reviewer 2


A 53-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/25/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination.  The physician reviewer found that according to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, breast tomosynthesis performed on 7/25/16 was likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the service at issue was 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 1


A 53-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/25/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination.  The physician reviewer found that there is evidence based support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely to be more effective than had her examination been performed using two dimensional imaging alone. Based upon the information set forth above, the service at issue was 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 60-year-old female enrollee has requested reimbursement for gene tests performed on 6/09/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees non-small cell lung cancer. The physician reviewer found that the therapy of advanced non-small cell lung cancer has been revolutionized by the finding of epidermal growth factor (EGFR) mutations in certain adenocarcinomas. The mutations are more common in those who have never smoked.  Even if stage IV disease is present, therapy targeted to EGFR with erlotinib results in prolonged survival when compared with standard chemotherapy regimens. The mutational landscape of non-small cell lung cancer has significantly expanded in the past two to three years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. Generally, KRAS, TP53, and BRAF are included in these panels and are informative. KRAS and EGFR mutations are usually mutually exclusive, so a sample with KRAS mutation does not need to be further analyzed for EGFR mutation. Patients on targeted therapy do develop resistance to erlotinib, and this too may be appreciated at the genetic level by recognition of new mutations or amplifications in parallel signal transduction pathways. BRAF mutations may suggest alternative targeted therapies that may be better than those selected empirically. ALK mutation or rearrangement is present in another subset of non-small cell lung cancer that may be amenable to targeted therapy with crizotinib. The medical evidence supports the services at issue in this patients case. Thus, gene tests performed on 6/09/16 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 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 63-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 3/08/19. 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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individualas melanoma cells. It then classifies that melanoma based on the five-year risk of metastasis. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is unknown if the DecisionDx-Melanoma assay can be used to make clinical decisions. Thus, DecisionDx-Melanoma testing provided on 3/08/19 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3 
 
The  parent  of  a  13-year-old  female  enrollee  has  requested  reimbursement  for  needle 
electromyography (EMG) of anal or urethral sphincter, any technique; needle electromyography,  each extremity; and electroencephalogram performed on 6/10/20. The Health Insurer has denied 
this request and reported that the services at issue were investigational for the treatment of the 
enrollees medical condition. The physician reviewer found that EMG of the anal sphincter and 
urethral sphincter are sensitive and specific methods for the diagnosis of loss of bowel and 
bladder  function  during  scoliosis  surgery,  in  addition  to  the  other  monitors  such  as 
somatosensory evoked potentials and motor evoked potentials. In combination with other 
monitors, they are a part of intraoperative neurophysiologic monitoring which is an essential part 
of scoliosis surgery and prevents iatrogenic neurological complications in real time. Therefore, 
needle  electromyography  (EMG)  of  anal  or  urethral  sphincter,  any  technique;  needle 
electromyography, each extremity; and electroencephalogram performed on 6/10/20 was likely 
to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 59-year-old female enrollee has requested reimbursement for Decision DX melanoma assay performed on 5/19/16.  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 the prognosis of cutaneous melanoma has classically been determined by the applying the staging system spelled out by Balch.  Mitotic index has also been thought to add to these statistics.  By Balch tables, this patients melanoma would be classified as a T1a melanoma, or stage 1A.  Such a tumor would have a predicted ten year survival of at least 88%.  Decision DX melanoma assay is a study of 31 genes in melanoma cells.  It then classifies that particular melanoma as either Class 1 (with a 97% disease free rate at five years) or Class 2 (with a 20-30% disease free rate at five years).  Gerami reported on 217 cases, with good correlation between prognosis and Decision DX classification, in patients undergoing sentinel node sampling.  However, it is not clear as yet how Decision DX data compares to the ten-year data of Balch determinations, and whether it can be used additionally to make clinical decisions.  This is especially in question in this particular patient, given her pathologic findings and excellent prognosis.  Thus, Decision DX melanoma assay performed on 5/19/16 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: Experimental
Decision: Overturned

Summary Reviewer 2


A 38-year-old male enrollee has requested authorization and coverage for cervical disc prosthesis.  The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition.  The physician reviewer found there is sufficient support for the requested services in this patients case.  The medical literature indicates an initial advantage to cervical disc replacement compared to anterior cervical discectomy and fusion.  However, long-term results appear to demonstrate a slight advantage to total disc arthroplasty.  In their study published in 2015, Davis and colleagues evaluated the safety and effectiveness of two-level total disc replacement using a Mobi-C cervical artificial disc at 48 months follow-up.  The conclusions were that this study continues to support total disc replacement as a safe, effective, and statistically superior alternative to anterior cervical discectomy and fusion for the treatment of degenerative disc disease at two contiguous cervical levels.  Thus, the requested cervical disc prosthesis is likely to be more efficacious than other treatment options.  Therefore, 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 3

A 46-year-old female enrollee has requested reimbursement for CPT code 84999 performed on 1/12/17. 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 the 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 the 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 novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, CPT code 84999 performed on 1/12/17 was not likely to have been more efficacious than other available 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: Overturned

Summary Reviewer 2

The parent of a 13-year-old male enrollee has requested authorization and coverage for Privigen. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that IVIG has potential risks associated with its use. Katz and colleagues noted, Most adverse effects are mild and transient including headaches, flushing, fever, chills, fatigue, nausea, diarrhea, blood pressure changes and tachycardia. IgA deficiency-related anaphylactic reactions are largely preventable. Late adverse events are rare and include acute renal failure and thromboembolic events. There remains significant debate regarding the diagnosis and treatment of PANDAS and PANS. In sum, Privigen is not likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 58-year-old male enrollee has requested reimbursement for test for allergy or toxicity (immunoglobulin G (IgG) food sensitivity testing) performed on 3/14/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of diarrhea. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. If there is concern that the patient may have celiac disease, the proper test is a tissue transglutaminase antibody or endomysial antibody. The testing performed in this case was not indicated. Therefore, the test for allergy or toxicity (IgG food sensitivity testing) performed on 3/14/18 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: Experimental
Decision: Upheld

Summary Reviewer 1

A 48-year-old female enrollee has requested reimbursement for genetic testing performed by Myriad Laboratories on 10/4/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for breast or ovarian cancer syndrome. The physician reviewer found that per the National Comprehensive Cancer Network (NCCN) guidelines, a first degree relative with ovary cancer, such as this patient, qualifies for BRCA testing, which was approved. However, there is a lack of scientific data to support the remaining portions of the genetic testing performed in this patients evaluation. Therefore, the genetic testing performed by Myriad Laboratories performed on 10/4/17 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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
A 51-year-old female enrollee has requested authorization and coverage for 64628  thermal 
destruction of intraosseous basivertebral nerve. The Health Insurer has denied this request and 
reported that the requested service is investigational for the treatment of the enrollees low back 
pain. At issue is whether 64628  thermal destruction of intraosseous basivertebral nerve is likely 
to be more beneficial for treatment of the enrollee's condition than any available standard therapy. 
The  physician  reviewer  found  that  the  requested  service  suggested  for  the  treatment  of 
vertebrogenic back pain in patients with Modic changes on imaging. Conger and colleagues report, 
There is moderate-quality evidence that suggests this procedure is effective in reducing pain and 
disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic 
changes, among other inclusion and exclusion criteria used in the published literature to date. 
Success of the procedure appears to be dependent on effective targeting of the basivertebral nerve. 
Non-industry funded high-quality, large prospective studies are needed to confirm these findings.  
Fischgrund and colleagues concluded, Chronic low back pain patients treated with basivertebral 
nerve ablation exhibit sustained clinical improvements in function and pain with high responder 
rates at a mean of 6.4 years following treatment. Basivertebral nerve ablation is a durable, 
minimally invasive treatment for vertebrogenic chronic low back pain. Smuck and colleagues  report, Basivertebral nerve ablation demonstrates significant improvements in pain and function 
over standard care, with treatment results sustained through 12 months in patients with chronic 
low back pain of vertebrogenic origin. Standard therapy for chronic low back pain includes 
physical therapy, medications, activity modification, and weight loss. There is a lack of treatment 
options designed to specifically target patients with Modic changes. Current medical literature 
demonstrates that the requested treatment is expected to be superior to standard conservative care 
for the treatment of this patients condition. Further, the results from studies demonstrate a 
reduction in pain, improvement in function, and durability of efficacy even beyond five years. 
Therefore, 64628  thermal destruction of intraosseous basivertebral nerve is likely to be more 
beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 54-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/06/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who has a history of breast cancer. The physician reviewer found that breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 54-year-old male has requested reimbursement for genetic testing performed on 2/04/16. 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 that Foundation One assay is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay would identify a specific target which could inform the clinician as to what chemotherapeutic agent would be useful. Thus far, however, there is a lack of convincing evidence that the assay adds to the decision-making ability or yields a result that is reliably clinically beneficial.  There are a variety of non-randomized studies exploring the value of molecular profiling, none of which have offered convincing evidence of the efficacy of this approach.  A randomized study by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular assay versus by the oncologists clinical judgment. The demonstration of a mutation on assay does not guarantee that a drug targeted at the mutation will be useful.  In sum, genetic testing performed on 2/04/16 was not 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 40-year-old female enrollee has requested reimbursement for homocysteine testing and polymerase chain reaction testing for EBV performed on 8/08/18. 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 the submitted records fails to demonstrate the superior effectiveness of the services at issue. The records do not document a history of homocystinuria, a coagulation disorder such as deep vein thrombosis or pulmonary embolism. The literature does not support the homocysteine level in this setting. With regards to polymerase chain reaction testing for Epstein Barr virus, the records do not document a history of post-transplant lymphoproliferative disorder, lymphoma or an immune compromised state. She has mild liver function elevation that is non-specific. Although Epstein Barr virus antibody testing may have been appropriate, there was no indication for polymerase chain reaction testing. The literature does not support routine use of polymerase chain reaction testing for Epstein Barr virus. In sum, homocysteine testing and polymerase chain reaction testing for Epstein Barr virus performed on 8/08/18 were not likely to have been of greater benefit than other methods of evaluating this patient.