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

Summary Reviewer 3

A 63-year-old female has requested reimbursement for Anser ADA testing provided on 4/25/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found there is insufficient medical evidence to support the effectiveness of Anser ADA compared with conventional courses of action in the management of ulcerative colitis. Patients being treated with adalimumab may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear. The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature. These small studies demonstrated, at best, correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect.  Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking.  Therefore, the clinical literature has not established the superior efficacy of Anser ADA testing performed on 4/25/16.  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 3

A 59-year-old female enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan performed on 2/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees rigidity, lack of response to Sinemet trial, with suspected Parkinsons disease. The physician reviewer found that in the current medical literature, DAT SPECT imaging of the brain has been shown to be helpful in the diagnosis of suspected Parkinsons disease. The agent used is a specific isotope which localizes areas of differential function (Djang, et al). In this patients case, the use of the DAT SPECT scan assisted in the diagnosis of Parkinsons disease, which in turn prompted treatment. All told, the peer-reviewed medical literature supports the clinical utility of the SPECT scan at issue as useful and likely to be more beneficial in evaluating and treating this patient than any available modality. Based upon the information set forth above, I have determined 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 60-year-old female enrollee has requested reimbursement for genomic analysis performed on 6/15/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ovarian cancer. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. In order to demonstrate the clinical utility of panel testing for somatic genomic alterations, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with the standard of care. The available literature on clinical utility consists of a small number of uncontrolled studies and nonrandomized controlled trials that use imperfect comparators. This evidence is not sufficient to make conclusions on clinical utility. In addition, there is potential for harm if ineffective therapy is given based on test results. Therefore, genomic analysis performed on 6/15/17 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

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 this patient has a history of PANS and current documented autoimmune encephalitis. He has been under the care of numerous specialists, with multiple hospitalizations, psychiatric admissions, and almost two months at a long-term care facility. Despite treatments with steroid burst, psychotherapy, and numerous psychoactive medications, he continued to have severe symptoms, including oppressive suicidal ideation. Only after beginning treatment with appropriately dosed IVIG have the neuropsychiatric symptoms started to recede. Therefore, Privigen is likely to be more beneficial than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 32-year-old male enrollee has requested reimbursement for partial hospitalization services from 1/20/17 through 2/10/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the documentation provided does not support the medical necessity for the services at issue in this clinical setting.  The patient had no withdrawal symptoms. He showed no evidence of being a danger to self or others.  He was cognitively intact and there were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  He was medically and psychiatrically stable. The patient noted that he had not attempted treatment at lower levels of care.  There was no evidence that treatment at a lower level of care would cause relapse or decompensation.  This patient was motivated and engaged in the recovery process.  He had support systems in place. He could have received treatment at a lower level of care. As such, the PHP services for substance use disorders from 1/20/17 through 2/10/17 were not medically necessary for treatment of this patient. Therefore, for the reasons stated above, 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: Overturned

Summary Reviewer 1


The parent of a six-year-old male enrollee has requested authorization and coverage for Saizen 8.8 mg click easy cartridge.  The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition The physician reviewer found there is sufficient support for the requested medication in this clinical setting.  This patient was born small for gestational age with lack of catch-up growth, growth hormone abnormalities (indicative of deficiency without stimulation testing), and small pituitary gland on MRI.  He was treated successfully in the past, with significant improvement in growth velocity, but the medication was discontinued prematurely and his height is now more than two standard deviations below the mean.  There are two ways to determine duration of therapy: administration of growth hormone when near adult height is achieved, or discontinuation of therapy when the height is in the normal adult range, less than two standard deviations from the mean. Either course of action is appropriate.  All told, Saizen 8.8 mg click easy cartridge is likely to be of greater benefit than other treatment options.  Based upon the information set forth above, the requested medication 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 38-year-old male enrollee has requested reimbursement for genetic testing performed on 5/31/18. 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 there is sufficient support for the services at issue in this clinical setting. This patients initial biopsy was suspicious for follicular neoplasm. Genetic testing could obviate the need for a surgical procedure. Genetic testing on thyroid nodules is generally considered standard protocol on all fine needle aspirations done on thyroid nodules. The literature indicates that this testing can be performed to avoid unnecessary surgeries. The results from this testing may influence patient management. Thus, genetic testing performed on 5/31/18 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 34-year-old female enrollee has requested reimbursement for genetic testing for birth defects performed on 3/28/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the American College of Obstetricians and Gynecologists recommends cell free fetal DNA to be utilized as a primary screening test in women at increased risk of aneuploidy. This includes women aged 35 years or older, women with a positive first-trimester or second-trimester screening test result, fetuses with ultrasonographic findings that indicate an increased risk of aneuploidy, women with a history of a child affected with a trisomy, or a parent carrying a balanced Robertsonian translocation with increased risk of trisomy 13 or trisomy 21. In this case, the patient does not meet any of these criteria, thus the testing was not indicated. Therefore, the testing at issue 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 

A 25-year-old female enrollee has requested authorization and coverage for surgery to remove the uterus (laparoscopic or laparoscopic assisted vaginal hysterectomy). 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 abnormal uterine bleeding is a common gynecologic problem. Prolonged uterine bleeding can result in anemia and interfere with daily activities, as in this case. Abnormal uterine bleeding encompasses a heterogeneous group of conditions with diverse etiologies. Diagnosing the etiology of the abnormal uterine bleeding involves a thorough history, physical examination, imaging, and endometrial sampling. This patient has undergone a thorough evaluation, with no distinct etiology found. Initial management usually consists of progestin-based treatments, including combination oral contraceptive pills, the 52 mg levonorgestrel-releasing intrauterine device, and tranexamic acid. Surgical treatment options include endometrial ablation for patients who desire uterine sparing or definitive treatment with hysterectomy for patient who have completed childbearing.  In this case, the patient has failed medical management options, including oral contraceptive pills and a short trial of Mirena intrauterine device, which she was unable to tolerate. She is not a candidate for tranexamic acid, given her prolonged bleeding pattern (greater than five days per month) and is not a candidate for endometrial ablation given her age and high risk of failure. The patient desires definitive management hysterectomy. Given that she has completed childbearing status-post bilateral salpingectomy, a hysterectomy is appropriate for this patient. Therefore, surgery to remove the uterus (laparoscopic or laparoscopic assisted vaginal hysterectomy) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 66-year-old male with a history of chronic neck pain associated with severe central
spinal stenosis at C5-6 and moderately severe spinal stenosis at C6-7, cord compression, and
myelopathy. The clinical examination corroborates the MRI findings with severe pain, disability,
and spinal cord compression at C5-6. The physician reviewer found that based upon the clinical findings corroborating the imaging findings and severe two-level
degenerative disc disease with myelopathy, there is a need for urgent decompression. Per the
current medical literature, a two-level total disc replacement at C5-6 and C6-7 is indicated. In the
study referenced here, 599 patients were followed for seven years. At seven years, the two-level
total disc replacement was found to be superior to anterior cervical discectomy and fusion. There
were lower rates of revision surgery and lower rates of adjacent level disc disease. The surgery
was very effective in relieving pain. Complication rate was very low. Overall, greater than 95% of
patients were AaAvery satisfiedAaA at seven years. There is sufficient support for the requested services
in this clinical setting. Therefore, the requested cervical disc arthroplasty is medically necessary
for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 27-year-old female enrollee has requested reimbursement for CPT code 63659 (percutaneous implantation of neurostimulator electrode array, epidural) provided on 11/25/19. The Health Insurer has denied this request and reported that the device at issue was not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. A case report by Lee and colleagues demonstrated efficacy for the use of spinal cord stimulation for Sphincter of Oddi dysfunction. The researchers noted a reduction in visual analog pain scores as well as a reduction in opioid consumption. In this case, the patient had chronic abdominal pain believed to be due to Sphincter of Oddi dysfunction. She had exhausted many of the standard therapeutic options, including nerve blocks, ERCP, stenting, as well as cognitive behavioral therapy and acupuncture, all with little benefit. She underwent a spinal cord stimulator trial and prior psychological screening and received significant improvement in her pain and a reduction in her opioid consumption. The medical literature has shown efficacy of spinal cord stimulation for this indication. This patient validated the efficacy of this treatment for her condition by performing a stimulator trial. Therefore, CPT code 63650 (percutaneous implantation of neurostimulator electrode array, epidural) provided on 11/25/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is a 26-year-old female with a history of major depressive disorder. The patient has 
requested  authorization  and  coverage  for  six  additional  sessions  of  adult  mental  health 
transcranial magnetic stimulation. The physician reviewer found that per the literature, TMS is 
indicated for severe, recurrent major depressive disorder that has not responded to traditional 
medication and psychotherapy treatment. This patient qualifies for the diagnosis of treatment 
refractory depression given that she has failed more than three antidepressant trials in addition 
to psychotherapy. Additionally, she was evaluated by a psychiatrist who recommended TMS. The 
patient made significant gains with the beginning of TMS treatment, and it would be ill advised 
to discontinue this treatment before she has completed a full treatment cycle, as defined by the 
TMS psychiatrist. The medical evidence supports the use of TMS at this point in the decision-
making algorithm for treatment-refractory depression. TMS is the appropriate next step in the 
treatment of this patient and should be completed until the patient has achieved maximal effect 
from this treatment. Therefore,  six additional sessions of  adult mental health transcranial 
magnetic stimulation are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of an 11-year-old male enrollee has requested authorization and coverage for child mental health outpatient services with Robert Colegrove, EdD. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee, who has a history of inattentive behavior, anxiety, avoidance behaviors, and difficulty with impulse control. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Per the records, psychological testing was requested to aid with determining the patients diagnosis and clarifying a written diagnosis of attention deficit/hyperactivity disorder. Psychological and neuropsychological tests are not mandatory for the diagnosis of attention deficit/hyperactivity disorder. The current standard of care for the diagnosis of attention deficit/hyperactivity disorder is through full clinical evaluation. In this case, the documentation suggests a diagnosis of attention deficit/hyperactivity disorder.  Based on the current evidence, attention deficit/hyperactivity disorder is a clinical diagnosis, and testing is not needed to establish this diagnosis. Thus, the requested child mental health outpatient services with Robert Colegrove, EdD are not medically necessary for the treatment of this patient. Therefore, the requested services are 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 46-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 1/21/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found the breast tomosynthesis performed on 1/21/15 was not likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The study by Howard and colleagues states Initial imaging for women with breast pain increased the odds of subsequent clinical utilization and did not increase reassurance in ruling out malignancy. In this case, the patients routine imaging studies as well as the sonogram was negative. Her breasts were described as having scattered fibroglandular elements, and were not dense. In addition, her studies were unchanged when compared to prior mammograms. In addition, breast pain is rarely associated with breast cancer, especially without a recognizable mass. If there had been a recognizable mass seen on the mammogram or sonogram, there may have been an indication for tomosynthesis. For the reasons provided, in this clinical setting the breast tomosynthesis was not likely to be more beneficial for evaluation of the patients medical condition than available standard 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 61-year-old male enrollee has requested reimbursement for genetic testing (81201, 81210, 81211, 81235, 81292, 81295, 81298 and 81321) performed on 2/13/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees metastatic colon cancer to the lung. The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue. It has not been established if molecular markers are useful in treatment determination (predictive markers) and prognosis other than for KRAS, NRAS, and BRAF mutation testing, microsatellite instability, and mismatch repair testing. Multiple clinical trials that are attempting to validate this personalized or precision medicine approach are in various stages of development and execution. Although preliminary data from some of these efforts have fueled excitement about the utility of these studies, their execution has also provoked many questions about the best way to approach complicating factors, such as tumor heterogeneity and the choice of which genetic mutations to target. Currently, it is unclear if molecular profiling is beneficial in identifying potential targets for treatment. Additionally, if targets are identified, it is unclear if targeted treatment is beneficial. In this patients case, the current evidence supports a portion of the services at issue. Specifically, 81210 (BRAF), 81235 (EGFR gene analysis, common variants), 81292 (MLH1 gene full sequence), 81295 (MSH2 gene full sequence) and 81298 (MSH6 gene full sequence) were medically necessary for the evaluation of this patient. However, the medical necessity of the remaining tests performed has not been established. Therefore, a portion of the services at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

The parent of a 15-year-old male enrollee has requested reimbursement for quantification of therapeutic drug, not elsewhere specified and immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified, performed on 12/10/19. 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 therapeutic infliximab drug levels and antibodies are now considered as standard of care for management of patients on Remicade. Sufficient drug levels and negative antibody levels are important to maintain long-term efficacy of the drug. Modification of drug dose based on symptoms and/or levels and antibodies may help sustain continued remission. In this patientas case, he was symptomatic the day prior to the infusion. There was evidence of poor bone health, suggesting possible active disease. The medical evidence supports the services at issue in this clinical setting. All told, quantification of therapeutic drug, not elsewhere specified and immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified, performed on 12/10/19 was likely to have been more beneficial than other methods of evaluating this patient.