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

Summary Reviewer 2

A 22-year-old male enrollee has requested reimbursement for surgical treatment of femoroacetabular impingement syndrome performed on 12/23/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees hip pain. The physician reviewer found that femoral and/or acetabular bone can develop rough edges or an irregular shape, which can subsequently impinge against the bone and soft tissues, causing tendon/labral/capsular damage. It has been theorized that by shaving and contouring the bony prominences, surgeons might protect patients from further injury and prevent additional arthritic progression. Short-term results showed that individuals with greater than 2 mm of joint space might expect some improvement in pain and function after hip arthroscopy for femoroacetabular impingement. Degen and colleagues reported that a cohort of 86 competitive baseball players undergoing femoroacetabular impingement surgery had 88% return-to-sport rate. In this case, the patient had insidious onset of symptoms for greater than six months prior to surgical treatment. There is documented evidence of a failed conservative management program to include intraarticular corticosteroid injection, activity modification and a formal course of physical therapy. The records documents well-preserved joint space and radiographic findings consistent with femoroacetabular impingement. While the literature is lacking high-quality randomized controlled trials, there is a propensity of studies consistently demonstrating benefit in this clinical setting (young age, no advanced degenerative changes on imaging and classic physical examination findings with corroborating imaging). Except for hip arthroplasty, which should be the option of last resort in a patient of this age, there was a lack of other reasonable treatment interventions which have been shown to be efficacious. There is sufficient support for the services at issue in this patients case. In sum, surgical treatment of femoroacetabular impingement syndrome performed on 12/23/15 was likely to have been more effective than other treatment alternatives. 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: Experimental
Decision: Upheld

Summary Reviewer 1

A 35-year-old female enrollee has requested reimbursement for homocysteine testing provided on 6/05/18 and 7/16/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who had a history of miscarriage. The physician reviewer found that Homocysteine testing is not recommended as part of the investigation for pregnancy loss.  In order to initiate an investigation for pregnancy loss, there should be a demonstration of recurrence. This patient has not had recurrent pregnancy loss. Even in the case of recurrent pregnancy loss, checking the level of homocysteine is not recommended.  There is no clinical utility to this evaluation.  All woman are advised to take adequate folate in the form of diet or supplement. The homocysteine level would not impact this recommendation. Therefore, homocysteine testing provided on 6/05/18 and 7/16/18 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 3

A 52-year-old male requested authorization and coverage for hypoglossal stimulator.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea. The physician reviewer found that there are multiple references supporting the efficacy of hypoglossal stimulator in this clinical setting. However, further studies comparing this intervention with conventional therapies are needed to definitively evaluate outcomes (Certal et al). In this patients case, there is a lack of records that indicates other procedures have been tried and failed. The provider does suggest that the patient would meet clinical criteria for consideration of hypoglossal nerve stimulator therapy for improvement of the symptoms of snoring and apnea. However, the records do not indicate that this patient has undergone other methods of management.  Specifically, other surgical procedures have not been attempted such as improvement of the nasal airway with turbinate reduction and possible nasal septal reconstruction.  These methods have not been shown to improve sleep apnea, but can improve tolerance to nasal CPAP therapy. Additionally, the patient may be a candidate for other traditional oropharyngeal surgery such as uvulopalatopharyngoplasty with tonsillectomy which may improve this patients symptoms. In summary, hypoglossal stimulator is not likely to be more effective than conventional therapies for treatment of this patients medical condition.Therefore, for the reasons stated 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 50-year-old female enrollee has requested authorization and coverage for Aimovig. 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 this patient has a history of migraines. She has already been on several nonspecific oral preventives for migraines. The medical evidence support the use of Aimovig for the preventive management of migraines in adults. Per American Headache Society guidelines, prevention is warranted for people with three migraine days monthly. In this patients case, she reported that she experiences five to six migraines per month. Guidelines also noted that individuals who fail greater than two prior preventives are appropriate for calcitonin gene-related peptide (CGRP) therapies. She meets this guidance. In addition, the Health Insurer noted that the patient was started on Aimovig 140 mg. Review of the data regarding Aimovig reveals that this is a more effective dose than 70 mg. It is appropriate to start patients on what is likely to be most effective as a standard part of clinical care. Therefore, Aimovig (erenumab-aooe subcutaneous solution auto-injector 140 mg/mL) is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 52-year-old female enrollee has requested reimbursement for gene testing (unlisted multianalyte assay with algorithmic analysis) performed on 12/21/18. 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 this patient has an early stage melanoma. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. All told, gene testing (unlisted multianalyte assay with algorithmic analysis) performed on 12/21/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 58-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing provided on 4/24/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma Gene Assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of this patients melanoma. Moreover, the DecisionDx-Melanoma Gene Assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma Gene Assay provided on 4/24/17 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: Overturned

Summary Reviewer 

The patient is a 47-year-old female who has requested authorization and coverage for Neulasta. She underwent chemotherapy for breast cancer. The patient has requested authorization and coverage for Neulasta. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting. Neulasta has been approved by the U.S. Food and Drug Administration to decrease the incidence of infection (as manifested by febrile neutropenia) in patients with non-myeloid malignancies receiving myelosuppressive cancer chemotherapy associated with a clinically significant incidence of febrile neutropenia. The combination of Adriamycin and cyclophosphamide carries a high risk of neutropenic fever. The standard of care is administration in a dose dense fashion every two weeks with growth factor support with Neulasta. Therefore, Neulasta is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 51-year-old female enrollee has requested reimbursement for hyaluronan knee injections performed on 12/6/17. 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 there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Maheu and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the hyaluronan knee injections performed on 12/6/17 were medically necessary for treatment of this patients medical condition. Based on the foregoing, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1 
 
A 47-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 8/26/21. 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 use of gene expression profiling (GEP) testing to differentiate melanomas 
at  low  versus  high  risk  for  metastasis  should  not  replace  pathologic  staging  procedures. 
Moreover, since there is a low probability of metastasis in stage I melanoma and a higher 
proportion of false-positive result, GEP testing should not guide clinical decision making in this 
group. Commercially available GEPs, such as DecisionDx-Melanoma testing, are marketed as 
being able to classify cutaneous melanoma into separate categories based on risk of metastasis. 
However, it remains unclear where these GEP platforms provide clinically actionable prognostic 
information when used in addition to or in comparison with known clinicopathologic factors or 
multivariate  nomograms  that  incorporate  patient  sex,  age,  tumor  location  and  thickness, 
ulceration,  mitotic  rate,  lymphovascular  invasion,  and  sentinel  lymph  node  biopsy  status. 
Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not 
been established. Various (mostly retrospective) studies of prognostic GEP testing suggest its role 
as an independent predictor of worse outcome, although not superior to Breslow thickness or 
sentinel lymph node status. It remains unclear whether this GEP profile is reliably predictive of 
outcome across the risk spectrum of melanoma. Prospective validation studies are required to 
more  accurately  define  the  clinical  utility  of  molecular  testing  prior  to  widespread 
implementation  of  GEP  for  prognostication  of  cutaneous  melanoma,  and  in  particular  to 
determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant 
treatment decisions. Therefore, DecisionDx-Melanoma testing performed on 8/26/21 was not 
likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The patient is a 46-year-old female with severe cervical spondylosis with progressive involvement of C5-6 and C6-7 levels and associated radiculopathy. The patient has requested reimbursement for cervical artificial discectomy performed on 4/13/17. The Health Insurer has denied this request indicating that the surgery at issue was considered investigational. Cervical disc arthroplasty has been approved by the US Food and Drug Administration (FDA) and has been demonstrated preserve some motion and provide decreased incidence of adjacent level disease when compared with anterior cervical discectomy and fusion. The need for revision surgery is also less than anterior cervical discectomy and fusion (Gao, et al; Wu, et al; Radcliff, et al). For these reasons, the cervical artificial discectomy performed on 4/13/17 was 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 surgery at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 53-year-old female enrollee has requested authorization and coverage for a transcatheter aortic valve replacement (TAVR). 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 based on current guidelines, including the recent Partner 3 Trial, TAVR is considered superior to surgical aortic valve replacement (SAVR) in low risk patients with severe aortic stenosis. The one-year outcomes showed a significantly lower composite of death, stroke or re-hospitalization. However, as in prior TAVR trials, patients were excluded if they did not have severe aortic stenosis (a transvalvular gradient of at least 40 mmHg) and if the valve was bicuspid, as is the case with this who has a bicuspid valve and a gradient of only 26 mmHg. Therefore, the patient would not meet inclusion criteria in the relevant TAVR trials. Therefore, the requested TAVR is not likely to be more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 21-year-old female enrollee has requested reimbursement for partial hospitalization program level of care provided form 4/12/19 through 4/26/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. With regards to functional status, the records support a score of 2 due to an overall good functional level with appropriate activities of daily living. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability with controlled diabetes and no active substance use. With regards to level of stress of the recovery environment, the records support a score of 2 due to no mention of a stressful recovery environment. In terms of level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources. With regards to treatment and recovery history, the records support a score of 2 due to success in the treatment program with a good level of cooperation and stabilization of symptoms. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into her need for treatment. Thus, the patient has a composite score of 13. This score correlates with low intensity, community-based services.  Therefore, the patient did not meet criteria for partial hospitalization program level of care during the disputed timeframe. In sum, partial hospitalization program level of care provided from 4/12/19 through 4/26/19 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The parent of a 16-year-old female enrollee has requested authorization and coverage for Rituxan. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the use of Rituxan in this case is not likely to be more beneficial than the available standard therapy. According to the 2019 American College of Rheumatology/Arthritis Foundation guideline for the treatment of juvenile idiopathic arthritis, biologic medications available to treat children with juvenile idiopathic arthritis include Actemra, Enbrel, Humira, and Orencia after failure of standard DMARD therapy. According to the Rituxan prescribing information, it is indicated for the treatment of rheumatoid arthritis in combination with methotrexate in adult patients with moderately-to-severely active rheumatoid arthritis who have had an inadequate response to one or more tumor necrosis factor antagonist therapies. This patient has failed a single biologic therapy according to the medical records. There are other options that are considered a standard of care in this case, including Orencia intravenous or subcutaneous, Actemra intravenous or subcutaneous, or Enbrel. These medications are indicated for juvenile idiopathic arthritis.  There is no data available to suggest that this patient would respond more to Rituxan as opposed to the biologic medications that are approved for juvenile idiopathic arthritis. Thus, Rituxan is not likely to be more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The patient is a 50-year-old female with ZZ phenotype severe alpha-1-antitrypsin deficiency. The 
patient has requested authorization and coverage for Prolastin-C 1,000 mg/20 ml (J0256). The 
physician reviewer found that the submitted documentation fails to demonstrate the medical 
necessity of the requested medication. Prolastin-C augmentation treatment is not medically 
indicated because the patient does not have any evidence of airflow obstruction on pulmonary 
function testing. The GOLD guidelines cited below indicate that patients most likely to benefit 
from Prolastin-C should have a forced expiratory volume in one second (FEV1) between 35 to 
65% of predicted. Therefore, Prolastin-C 1,000 mg/20 ml (J0256) is not medically necessary for 
the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 60-year-old male enrollee has requested reimbursement for positron emission tomography (PET) performed on 3/08/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that this patient exhibited biochemical failure after treatment for prostate cancer as proven by steadily rising PSA levels. Routine imaging was unremarkable. In such cases, the use of a tracer to detect prostate cancer specific tissue is the current state of the art evaluation. This determination of site of recurrence is crucial in order to direct definitive treatment. Therefore, PET performed on 3/08/18 was 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 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: Overturned

Summary Reviewer 1

A 37-year-old female enrollee has requested authorization and coverage for lymphaticovenous anastomosis and intraoperative indocyanine green lymphatic mapping. 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 proposed procedure has been studied for over a decade, and the peer-reviewed literature supports the benefit of the procedure. Scaglioni and colleagues performed a systematic review of lymphovenous anastomosis for the treatment of lymphedema. The authors noted, aAlthough the studies included in this review showed great heterogeneity, lymphovenous anastomosis surgery revealed both objective and subjective improvements in most patients.a Thomas and colleagues noted, aThe findings suggest that the real impact of living with lymphedema is much more challenging than previously identified. The findings suggest that lymphovenous anastomosis can give a future of greater choice for some of its recipients, but further research should explore longer-term benefits. Lymphovenous anastomosis could offer hope to some people with lymphedema, but a realistic expectation is essential.a There is sufficient support for the requested services in this clinical setting. Therefore, lymphaticovenous anastomosis and intraoperative indocyanine green lymphatic mapping is likely to be more beneficial than other available standard therapy.