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

Summary Reviewer 

The parent of a six-year-old male enrollee has requested reimbursement and prospective authorization and coverage for mental health applied behavioral analysis from 1/13/19 through 7/13/19 (30 hour per week one-to-one therapy and H0031, 6 hours per month). The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The treatment authorization request included over 35 goals, most being social in nature. The purpose of supporting the patient in the educational settings is to provide training on social interactions with typical/same aged peers in a more naturalistic setting. The Behavior Analyst Certification Board (BACB) highlights that services are provided in multiple locations, including school settings, to promote generalization and maintenance of treatment gains. Further, the number of goals identified necessitates the treatment intensity described. The medical evidence supports the services at issue in this clinical setting. Therefore, mental health applied behavioral analysis from 1/13/19 through 7/13/19 (30 hours per week one-to-one therapy and H0031, six hours per month) was and is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 23-year-old female enrollee has requested reimbursement for genotype testing performed on 11/10/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees behavioral health conditions. The physician reviewer found that there is a lack of support for the services at issue in this patients case. Pharmacogenetics deals with the differences in effect of drugs due to individuals genetic variations. This testing may be beneficial for treatment-resistant patients in order to help predict response to certain medications. In this case, the records do not demonstrate that the patient was treatment-resistant. In this setting, the services at issue were not consistent with standards of good medical practice. Therefore, genotype testing performed on 11/10/17 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: Experimental
Decision: Overturned

Summary Reviewer 1


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 the Thyroid Trio testing comprises three different tests that are not routinely recommended by providers caring for patients with thyroid problems. There is a lack of medical literature supporting the utility of the MTHFR and NCV studies in this clinical setting. Further, the American Thyroid Association Task Force on Thyroid Hormone Replacement does not include the testing used in this case for evaluation of this patients medical condition. All told, the MTHFR and NCV studies performed on 9/22/15 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 64-year-old male enrollee has requested authorization and coverage for PET scan with CT for attenuation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that PET/CT is one of the most useful imaging examinations for the staging of malignancy, detection of recurrence or metastases, and monitoring of treatment response. Although the value of PET/CT is limited for the diagnosis of renal cell carcinoma due to renal excretion of fluorodeoxyglucose (FDG), PET/CT has been increasingly utilized to evaluate treatment response to targeted therapies, such as tyrosine kinase inhibitors. It has been shown that tumor size is not an accurate indicator of tumor response to these new targeted therapies, and functional imaging is more accurate. In this case, the patient is not currently being treated with a tyrosine kinase inhibitor. A follow-up chest CT is the appropriate imaging examination to assess pulmonary metastases. The records indicate that the patient was evaluated with a CT of the chest on 4/12/19. The results were adequate for appropriate monitoring of the patient. Only if the results were substantially equivocal would a PET/CT be indicated, and they were not. Therefore, the requested PET with CT for attenuation is not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 30-year-old male enrollee has requested reimbursement for immunoglobulin heavy chain locus gene rearrangement and immunoglobulin kappa light chain locus gene arrangement testing performed on 2/14/19. 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 leukemia and lymphoma are the most common causes of unexplained fever. Most patients with T-cell large granular lymphocyte (LGL) leukemia present with symptoms related to neutropenia. Fever with recurrent bacterial infections occurs in 20 to 40 percent of patients. LGL leukemia is a chronic illness. Usually, there is history of a gradual decline in counts over time. Diagnosis includes evaluation of T-cell rearrangements. B-lymphoblastic leukemia and lymphoma are overlapping clinical manifestations of the same disease. The tempo of disease is variable. Some patients present with symptoms that progress slowly over weeks to months, while others have a more acute presentation. Nearly all cases of B-cell acute lymphoblastic leukemia have rearrangements of immunoglobulin heavy chain (IGH), but up to 70 percent of cases also have rearrangements of the T-cell receptor (TCR) gamma or beta chain genes. Molecular techniques that can detect clonal populations of lymphocytes include polymerase chain reaction (PCR) and DNA sequencing. These techniques can demonstrate the presence of a dominant clone of cells based on rearrangements of either immunoglobulin genes (in B lymphocyte) or T-cell receptor genes (in T cells) and can include immunoglobulin heavy chain locus gene rearrangement and immunoglobulin kappa light chain locus gene. The services at issue were part of standard testing. Therefore, immunoglobulin heavy chain locus gene rearrangement and immunoglobulin kappa light chain locus gene arrangement testing performed on 2/14/19 were likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


The parent of a 17-year-old male enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 6/30/14. 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 submitted documentation fails to demonstrate the superior efficacy of the services at issue.  There is a lack of controlled data to support measurement of infliximab levels after completing an induction dose of Remicade.  Theoretically, one could find the unique dose requirement for each patient and tailor therapy individually.  However, this approach has not been shown to lead to improved outcomes.  There is a lack of support for the services at issue in this clinical setting.  Therefore, Prometheus Anser IFX testing was not likely to have been of greater benefit than other methods of evaluation.  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 28-year-old female enrollee has requested reimbursement and prospective authorization and 
coverage for ketamine infusions from 9/07/21 forward. The Health Insurer has denied this 
request and reported that the services at issue were and are investigational for the treatment of 
the enrollees medical condition. The physician reviewer found that the patient has a history of 
major  depressive  disorder  that  has  not  responded  to  multiple  antidepressants,  dialectical 
behavior therapy, eye movement desensitization and reprocessing, and transcranial magnetic 
stimulation. Her provider recommended intravenous ketamine infusions for treatment-resistant 
depression. Per the psychiatrist, the ketamine infusions have improved the patients quality of 
life and suicidal ideations. Currently, there is insufficient data on the long-term efficacy, safety, 
and tolerability of intravenous ketamine for patients with treatment-resistant depression. The 
U.S.  Food  and  Drug  Administration  has  approved  Spravato  (esketamine)  nasal  spray,  in 
conjunction with an oral antidepressant, for the treatment of depression in adults who have tried 
other antidepressant medicines but have not benefited from them. Like intravenous ketamine, 
esketamine nasal spray appears to have a robust and moderate effect on reducing symptoms of 
depression. To date, there is a lack of high quality data comparing the efficacy of intranasal to 
intravenous ketamine. Given this support, dosing with intravenous ketamine is not likely to be 
more beneficial than standard of care. Therefore, ketamine infusions from 9/07/21 forward were 
not and are not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 65-year-old female enrollee has requested authorization and coverage for Venclexta (venetoclax) 100 mg, five tablets daily #150. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees multiple myeloma. The physician reviewer found that Venclexta is not considered a standard of care for the treatment of patients with multiple myeloma. In addition, Venclexta is not U.S. Food and Drug Administration (FDA) approved for the treatment of multiple myeloma, supported major drug compenida, or the National Comprehensive Cancer Network (NCCN) guidelines. Venclexta has preliminary data from phase I trials showing it may only be efficacious for patients with certain genetic abnormalities and is the ongoing subject of clinical trials actively recruiting patients. Given the lack of data demonstrating improved patient health outcomes with use of Venclexta, the requested Venclexta (venetoclax) 100 mg, five tablets daily #150, is not supported 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 requested medication is 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: Upheld

Summary Reviewer 

A 48-year-old male enrollee has requested reimbursement for CPT code 84999 performed on 1/31/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees melanoma. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state 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. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. Thus, CPT code 84999 performed on 1/31/18 was not medically necessary for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 57-year-old female enrollee has requested authorization and coverage for Venclexta 100 mg, 240 for 30 days. 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 submitted documentation fails to demonstrate the medical necessity of the requested medication. Venclexta is U.S. Food and Drug Administration (FDA) approved for use in acute myeloid leukemia and chronic lymphocytic leukemia. It is not FDA approved for use in multiple myeloma or supported for off-label use in major drug compendia. Studies show promise, but these are phase I studies which show better efficacy in translocation t(11;14) and in combination with bortezomib and dexamethasone. In this patients case, she is requesting this medication in combination with carfilzomib, which is the subject of actively recruiting clinical trials. There is a lack of support for the requested medication in this clinical setting. Thus, Venclexta 100 mg tablets, 240 for 30 days are not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 59-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/30/16.  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 Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. In this particular patient, she has breasts containing multiple masses, many of which are changing in size.  The ability of better characterizing the margins of masses and establishing whether there might be suggestion of malignancy is a valuable advantage of tomosynthesis over other methods of testing.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Had there been no interval change, a tomosynthesis would not be indicated but considering the changes, tomosynthesis, for this patient, is helpful. Therefore, digital breast tomosynthesis performed on 8/30/16 was likely to have been of greater benefit than other modalities for 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: Upheld

Summary Reviewer 1

A 39-year-old male enrollee has requested authorization and coverage for corticotropin (H.P. Acthar Gel) injections, up to 40 units. 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 that the records fail to demonstrate the superior efficacy of the requested medication in this clinical setting. There is a lack of objective information, including physical examination, radiographs and confirmatory laboratory definitive studies, to establish a diagnosis of rheumatoid arthritis. The patient has features of various conditions. He has also not exhausted other treatment options, even if a diagnosis of rheumatoid arthritis has been established. The medical evidence supports the use of methotrexate or combination disease-modifying antirheumatic drug (DMARD) therapy, such as triple therapy with methotrexate, Plaquenil and sulfasalazine, unless contraindicated. A patient who fails DMARD therapy for rheumatoid arthritis is then a candidate for anti-tumor necrosis factor or other biologic therapies. This patient has already tried and failed two different steroids, including prednisone and Rayos. There is inadequate literature indicating that H.P. Acthar Gel is superior to these therapies in terms of efficacy or safety. Therefore, corticotropin (H.P. Acthar Gel) injections, up to 40 units is not likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 43-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 8/20/15. 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 that Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. In this case, however, there were no problems to be resolved. The patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. In addition, there had been no change when the current study was compared to prior studies. Her breasts were described as being composed almost entirely of fat. Tomosynthesis has not been shown to provide significant increased value in patients who have diffusely fatty breasts.  With diffusely fatty breasts, routine 2D mammography is highly accurate. As such, the breast tomosynthesis performed on 8/20/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available modalities. 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 62-year-old male enrollee has requested reimbursement for genetic testing performed on 
9/29/20. The Health Insurer has denied this request and reported that the services at issue were 
investigational for the evaluation of the enrollees medical condition. At issue is whether the 
services at issue were likely to have been more beneficial for evaluation of the enrollee's condition 
than any available standard therapy. The physician reviewer found that Decision Dx-SCC assay is 
a 40-gene assay exploring the genomic make-up of cutaneous invasive squamous cell cancer. This 
assay sorts the cancer into classes, each with a different rate of metastasis. The assay claims that 
it can predict the potential for metastasis, thereby changing the clinical approach to surveillance. 
At this time, however, it has not been shown to have a positive clinical impact above and beyond 
evaluation of the specific pathologic details of the individual cancer. It is not included within the 
National Comprehensive Cancer Network guidelines for squamous cell cancer. The medical 
evidence has not demonstrated the superior efficacy of the services at issue. Therefore, the genetic 
testing performed on 9/29/20 was not likely to have been more beneficial than any available 
standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 37-year-old male enrollee has requested reimbursement for small bowel overgrowth test panel (CPT codes 82491 and 91065) performed on 11/16/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found the medical literature supports the services at issue for this clinical situation. The patient presented with bloating. Bloating can be a sign of small intestinal bacterial overgrowth (SIBO). Accurate and definitive diagnosis can be difficult (Ponziani, et al). However, hydrogen breath testing is the most widely used diagnostic test for SIBO (Lacy, et al).  Testing for both hydrogen and methane increases the sensitivity of the breath test, and is a considerable improvement over hydrogen testing alone (Saad, et al; de Lacy Costello, et al). Antibiotics are necessary for treatment of SIBO. Confirmation of SIBO with breath testing avoids using empiric antibiotics for those patients who do not have SIBO, as in this case (Ponziani, et al).  Therefore, for the reasons stated above, the small bowel overgrowth test panel (CPT codes 82491 and 91065) performed on 11/16/15 was medically necessary for evaluation of this patient. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 42-year-old female enrollee requested authorization and coverage for CPT 58674 (Acessa procedure - laparoscopic radiofrequency ablation). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the patient is requesting a treatment for symptoms related to her fibroid uterus. She has heavy menstrual bleeding that has led to the need for treatment. The patient would like her fibroids treated with the Acessa procedure. Studies have supported the Acessa technique under certain clinical criteria for patient selection. One of the criterion is uterine size. The maximum allowable uterine size is 16 weeks gestational age. This patients uterus has several fibroids that measure 4.7  7.6 cm, thus meeting the size criteria. Another criterion is fibroid location. The fibroids are intramural, which falls within the procedure guidelines. The patient wishes to have a minimally invasive procedure to preserve fertility. It is likely that shrinking multiple fibroids will result in improvement in the patients pain and bleeding and improve her quality of life. Therefore, CPT 58674 (Acessa procedure - laparoscopic radiofrequency ablation) is likely to be more beneficial than any available standard therapy.