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

Summary Reviewer 


A 31-year-old male enrollee has requested authorization and coverage for anastrozole 1 mg. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient is being treated for testicular hypodysfunction with testosterone and human chorionic gonadotropin.  The laboratory studies from November 2015 and February 2016 show normal or high values of testosterone.  For men who are hypogonadal, as evidenced by clinical symptoms and signs consistent with androgen deficiency and a subnormal morning serum testosterone concentration on three separate occasions, testosterone replacement therapy is recommended. The approved uses for anastrozole 1 mg include first-line treatment of locally-advanced or metastatic breast cancer (hormone receptor-positive or unknown) in postmenopausal women, adjuvant treatment of early hormone receptor-positive breast cancer in postmenopausal women or treatment of advanced breast cancer in postmenopausal women with disease progression following tamoxifen therapy.  In this case, the patient does not have an approved indication for the use of anastrozole.  Furthermore, this medication is not recommended for the use of testicular hypofunction.  The documentation supports that the patient has had improved symptoms while taking testosterone and human chorionic gonadotropin.  Thus, the requested anastrozole 1 mg is not medically indicated for the treatment of this patient.  Therefore, 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: Upheld

Summary Reviewer 3

A 37-year-old male enrollee has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that the U.S. Food and Drug Administration (FDA) has approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate GERD and a hiatal hernia less than 3 cm. A recent study comparing the LINX procedure with laparoscopic fundoplication found that GERD patients had similar control of reflux symptoms after both LINX and fundoplication (Reynolds, et al). The inabilities to belch and vomit were significantly fewer with LINX, along with a significantly lower incidence of severe gas-bloat symptoms. In a group of 85 patients, augmentation of the lower esophageal sphincter (LES) with a magnetic device provided significant and sustained control of reflux, with minimal side effects or complications. No new safety risks emerged over a five-year follow-up period (Ganz, et al). This patient meets the specific criteria for LINX placement with a hiatal hernia that is only 0.2 cm larger than recommended for the procedure. All told, the requested LINX procedure is 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 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: Medical Necessity
Decision: Upheld

Summary Reviewer

The patient is a 40-year-old male with a history of cocaine abuse. The patient reported that his cocaine abuse started about nine years ago, and increased from intermittently to daily. He was previously treated in March 2016. The patient relapsed one day after discharge and spent the next 4.5 months using 1 gram of cocaine a day. He was then admitted to psychiatric residential treatment center (RTC) on 7/17/16 with the diagnoses of cocaine use disorder, severe and major depressive disorder, severe. He related a history of depression and noted that prior treatment with Lexapro many years ago was helpful. He denied any other psychiatric symptomatology, past or present. He denied any medical problems. He said he used alcohol occasionally and it did not represent a problem, and denied use of any other substance. He reported sleep disturbance. There was no prior history of blackouts or seizures. He denied suicidal or homicidal ideation. The patient participated actively in his treatment plan, involving multiple modalities including relapse prevention, individual therapy, and group therapy. He continuously struggled with issues of self-worth, shame, and feelings of loneliness. He was treated with Seroquel 50 mg and no other medications. His vital signs were stable, and cravings were reported as infrequent to none. The patient has requested reimbursement for psychiatric RTC services provided from 7/23/16 through 8/30/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. Post-acute withdrawal symptoms in cocaine use disorders are not to be expected, nor were anything akin to these reported.  He was not a danger to himself or others, and he was not violent or aggressive. There were no emotional, behavioral, or cognitive issues that warranted residential treatment. There was no evidence of mania or psychosis, or any other symptom complex which would have interfered with his recovery at a lower level of care. He was medically and psychiatrically stable. He was treated with Seroquel 50 mg and this was not adjusted. He was cooperative and engaged in his treatment. The issues addressed in his individual therapy did not require RTC level of care. The patient could have safely and effectively stepped down to a lower level of care as of 7/23/16. Thus, psychiatric RTC services provided from 7/23/16 through 8/30/16 were not medically necessary for treatment of the patients medical condition.  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

A 21-year-old male enrollee has requested reimbursement for polymerase chain reaction testing performed on 6/07/19. 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 this patient continued to have signs and symptoms of chronic prostatitis, including persistent pyuria, most commonly indicating infection. Standard diagnostic testing, including culture for chlamydia and gonorrhea, as well as bacterial pathogens, did not reveal the cause of the persistent prostatitis. Standard antibiotic regimens were tried and were not successful. At that point, the specimen was sent for next generation sequencing. Although next generation sequencing has not yet made it into most guidelines for diagnosis and treatment of urinary tract infections, it plays an increasing role in cases where traditional culture and standard treatment trials have failed in an individual patient. In this case, the patient had several trails of antibiotics and negative cultures for chlamydia and gonorrhea by traditional culture methods. Therefore, next generation sequencing was a reasonable next step in the diagnosis of persistent symptoms and pyuria. Thus, polymerase chain reaction testing performed on 6/07/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 60-year-old female enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) and nerve conduction velocity (NCV) studies provided on 9/22/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Hashimotos thyroiditis.   The physician reviewer found that Crone and Krarup noted diagnostic considerations for use of NCV are based on a flow chart classifying neuropathies into eight categories based on mode of onset, distribution, and electrophysiological findings, and the electrophysiological characteristics in each type of neuropathy are discussed. NCV is useful for evaluation of neurologic deficits but is not recommended in the absence of neurologic symptoms or physical findings. The medical records do not indicate physical exam findings of focal neurologic deficit or symptoms in support of NCV testing. In addition, NCV testing is not supported for evaluation of Hashimotos thyroiditis. As there are no neurologic symptoms or findings reported, NCV studies were not appropriate for evaluation of this patients medical condition. There is one publication in regard to MTHFR use for association with Hashimotos disease, but there is a lack of support for clinical application for individual clinical determination. Arakawa and colleagues found that some data suggests that a certain genotype correlates with DNA hypomethylation and with the intractability of goiter, and another genotype may correlate with the severity of Hashimotos disease. However, the authors noted that additional studies are needed to determine clinical correlation. Consistent with these findings, the MTHFR and NCV studies provided on 9/22/15 were 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: Upheld

Summary Reviewer 3


A 60-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that there is a lack of evidence in the medical literature to suggest that proton therapy for prostate cancer is associated with improved outcomes compared to standard treatment with intensity modulated radiation with image guidance. A recent comparative effectiveness study found no significant difference in toxicities between proton therapy and standard treatment (Sheets, et al). In addition, the National Comprehensive Cancer Network (NCCN) guidelines state that proton therapy for prostate cancer should not be performed outside of a clinical trial. Further, the American Society of Radiation Oncology (ASTRO) has also issued a position statement emphasizing that proton therapy should not be delivered for prostate cancer (Hahn, et al). Therefore, the requested proton beam radiation therapy is not likely to be more beneficial for the patients prostate cancer than standard therapy.  Based upon the information set forth above, I have determined 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 62-year-old female enrollee has requested authorization and coverage for Repatha SureClick 140 mg/mL. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the patient has a cardiomyopathy and a diagnosis of angina, although there is no documentation of testing for coronary artery disease. However, she does have severe hyperlipidemia and a strong family history of early coronary artery disease. In addition, she has been intolerant of multiple statin medications due to recurrent myalgias and also a trial of ezetimibe and bile acid resins which did not get her to LDL goal. Although the extent of established coronary artery disease is not clear, she does carry a diagnosis of angina and is prescribed nitroglycerin for this. In addition, she has severe baseline hyperlipidemia and a trial of statins and multiple other lipid lowering medications has been ineffective or not tolerated due to significant side effects necessitating discontinuation of these medications. There is little chance that lifestyle and dietary modifications would decrease her LDL to less than 100 (goal) without pharmacologic therapy. Since she is multi-statin intolerant and bile acid resins and ezetimibe have been ineffective, her only option is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor. Thus, Repatha is indicated for the treatment of this patient. Therefore, Repatha SureClick 140 mg/mL is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3 
 
A 46-year-old male enrollee has requested authorization and coverage for Acthar Gel. The Health 
Insurer has denied this request indicating that the requested medication is investigational for the 
treatment of the enrollees sarcoidosis. The physician reviewer found that while there is a lack of 
organizational guidelines on the treatment of sarcoidosis, based on case reports and small 
studies, sarcoidosis refractory to prednisone is frequently treated with disease modifying anti-
rheumatic drugs (DMARDs) such as methotrexate, Plaquenil, leflunomide, and infliximab. The 
FDA approves the use of Acthar Gel for the treatment of sarcoidosis. Baughman, and colleagues 
note an improvement in symptoms of fatigue, pulmonary function testing, chest imaging, and 
quality of life, along with decreasing prednisone doses with the use of repository corticotropin. 
Chopra and colleagues report that the use of repository corticotropin resulted in improvement 
in patients with advanced symptomatic sarcoidosis. In this clinical setting, given the side effects 
that may accompany standard therapies, the requested medication is likely to be more beneficial 
for the treatment of this patients sarcoidosis than available standard therapy. Therefore, Acthar 
Gel is likely to be more beneficial for treatment of the patients condition than any available 
standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 61-year-old female enrollee has requested reimbursement for the office visits provided on 5/20/16, 8/25/16, and 11/17/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees hypothyroidism, Hashimotos thyroiditis, menopause syndrome, and iron deficiency anemia. The physician reviewer found that Hypothyroidism, also called underactive thyroid or low thyroid, is a common disorder of the endocrine system in which the thyroid gland does not produce enough thyroid hormone. If not properly treated, hypothyroidism can cause a number of symptoms such as poor ability to tolerate cold, a feeling of fatigue, constipation, depression, and weight gain. LT4 monotherapy has emerged as the therapy of choice for treatment of hypothyroidism (Hennessey). However, due to the narrow therapeutic window of LT4, it is important to closely monitor dose selection and achievement of thyrotropin goals that are specific to the individual patients overall clinical situation (Jonklaas). Providers should follow patients closely in order to properly adjust their dosages of thyroid hormone therapy. For these reasons, the office visits provided on 5/20/16, 8/25/16, and 11/17/16 were 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 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 parent of an 11-year-old female enrollee has requested authorization and coverage for Nutropin.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees short stature. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication.  There is insufficient information provided to determine the medical necessity of continuation of growth hormone therapy.  As the case material includes a growth chart with only one data point, it is not possible to determine if this patient experienced poor growth velocity prior to growth hormone treatment.  In addition, no data are provided about pre-treatment IGF-1 or insulin-like growth factor binding protein 3 (IGFBP-3) levels, or pre-treatment laboratory work-up to rule out other causes of growth fall-off.  All told, Nutropin is not medically indicated for the treatment of this patient.  Therefore, 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: Upheld

Summary Reviewer 2

A 76-year-old male enrollee has requested reimbursement for the Oncotype DX Colon Cancer Assay (CPT 81525) performed on 10/25/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees stage II colon cancer. The physician reviewer found that the peer-reviewed medical literature has not established the utility of molecular markers in treatment determination and prognosis in patients with colon cancer. The Oncotype DX Colon Cancer Assay does not have specific U.S. Food and Drug Administration (FDA) approval for use in stage II colon cancer. Further, the assay has not been proven to predict which patients with stage II disease could benefit from adjuvant therapy. Moreover, the American Society of Clinical Oncology (ASCO) guidelines do not address use of this assay. Accordingly, the Oncotype DX Colon Cancer Assay (CPT 81525) performed on 10/25/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 30-year-old male enrollee has requested authorization and coverage for suction assisted lipectomy, trunk (CPT 15877) and mastectomy, simple complete (CPT 19303). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that Arya and colleagues stated, True gynecomastia refers to enlarged glandular tissue rather than deposition of fat tissue. Enlargement of breast due to deposition of fat in the breast area is known as pseudogynecomastia. Bellini and colleagues stated, In pseudogynecomastia, there is an increased development of the fatty component in the male breast region. In true gynecomastia, however, there is an increase in volume of the male breast gland with a dense fibrous and vascular stroma, which makes suction more difficult. The gynecomastia liposuction treatment is usually associated to a resection under direct vision of the glandular tissue through a periareolar or transareolar incision. Innocenti and colleagues stated, in regard to excision of gynecomastia, that If necessary, liposuction of the peripheral fatty tissue was usually performed. Liposuction for chest contouring of fatty tissue can be performed in addition to direct excision of glandular gynecomastia for an improved cosmetic result on the entire chest. Liposuction around the glandular tissue is not a separate technique but is rather a more efficient method of fat excision. Fatty tissue removal around the glandular tissue for contouring is an included part of excision of gynecomastia. It is not a separate procedure. Extensive liposuction to the anterior chest for removal of pseudogynecomastia and general chest contouring is not medically necessary and is a cosmetic procedure. Suction assisted lipectomy trunk (CPT 15877) is not medically necessary as a separately billed procedure. In this case, the Health Insurer declined coverage for 19303 because the code is for a mastectomy in a woman. However, the Health Insurer did approve 19300 on appeal because that applied to a mastectomy for gynecomastia in a male. CPT 19303 is not medically necessary because it applies to a mastectomy in a woman. Therefore, suction assisted lipectomy, trunk (CPT 15877) and mastectomy, simple complete (CPT 19303) are not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3 
  An  83-year-old  male  enrollee  has  requested  reimbursement  for  Guardant360  CDx  testing 
performed on 3/31/21. 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 therapy of advanced NSCLC has been revolutionized by the finding of 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. In this case, it was 
important to know whether the patient had developed an EGFR T790M mutation. This mutation 
confers resistance to erlotinib and has been observed in 60% of patients with progressive disease 
on erlotinib. There is a new tyrosine kinase inhibitor available that can target this mutation, 
osimertinib, which could have been used if this mutation was observed. In order to analyze for 
this mutation, a liquid biopsy was ordered. The Guardant360 test is commonly referred to as a 
liquid biopsy since it involves sampling of tumor cells that may be circulating in the peripheral 
blood. Up to 70 genes can be analyzed for mutations. The test is known for high specificity but 
low sensitivity. According to the NCCN guidelines, it is associated with false negative rates of up 
to 30%. The guidelines note that the test is acceptable if the patient is unfit to pursue more 
invasive methods for tumor sampling. If a simple core biopsy of an accessible metastatic lymph 
node, like a supraclavicular or axillary lymph node, was feasible, then a Guardant360 testing 
would have been unreasonable; but that is not the case here. Per the submitted records, the 
tumor sample was noted as being inadequate for subsequent analysis. There was sufficient 
support  for  Guardant360  testing  in  this  setting  since  disease  was  inaccessible.  Therefore, 
Guardant360 CDx testing performed on 3/31/21 was likely to have been more beneficial for 
evaluation of the patients medical condition than any available standard therapy.