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

Summary Reviewer 3


A 59-year-old male enrollee has requested reimbursement for advanced lipoprotein testing provided on 3/11/16. The Health Plan has denied this request indicating that the service at issue was considered investigational for the enrollees hypertension. The physician reviewer found there is a lack of support in the peer-reviewed medical literature demonstrating that lipoprotein testing is more beneficial than standard therapy. Advanced lipoprotein testing has not been shown in the scientific data to definitively improve health outcomes compared to the use of standard lipid profiles utilized to make therapeutic lipid lowering decisions. For the reasons stated above, the advanced lipoprotein testing performed on 3/11/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 63-year-old male enrollee has requested authorization and coverage for transcatheter radiofrequency ablation. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees paroxysmal atrial fibrillation.   The physician reviewer found that based on the records provided, this patient presents with symptomatic paroxysmal atrial fibrillation and relative contraindication to trials of antiarrhythmic medication due to intermittent bradycardia and pauses. In this circumstance, current guidelines for the management of atrial fibrillation consider catheter ablation appropriate therapy if there is failure or intolerance at least one anti-arrhythmic medication (January, et al; Calkins, et al). Since this patient has relative contraindication to antiarrhythmic medication, proceeding to ablation is reasonable, appropriate and considered standard accepted practice in the medical community. Moreover, this patients symptomatic atrial fibrillation has a more favorable chance of success with ablation since it is paroxysmal. For these reasons, the requested transcatheter radiofrequency ablation 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 service 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: Upheld

Summary Reviewer 3


A 60-year-old female enrollee has requested reimbursement for DecisionDX Melanoma gene expression assay performed on 12/23/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found there is a lack of high-grade scientific data to support the superior efficacy of the services at issue in this clinical setting. The DecisionDX Melanoma gene expression assay has not been clinically shown to add to the current standard of care for the evaluation of malignant melanoma. Therefore, the DecisionDX Melanoma gene expression assay performed on 12/23/15 was not likely to be more effective than standard treatment for the evaluation of 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 3


A 32-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees asthma.  The physician reviewer found that Bronchial thermoplasty is a procedure that uses a bronchoscope probe/catheter to provide thermal energy to the smooth muscle of the airway. There are three bronchoscopy procedures. The first treats the right lower lobe. The second treats the left lower lobe and the third procedure is for both upper lobes. The procedures are scheduled about three weeks apart. However, bronchial thermoplasty is not generally accepted as the standard of care for the treatment of asthma. There is inadequate scientific data demonstrating an increase in forced expiratory volume (FEV)-1 with this treatment. In addition, a recent publication noting the safety of the procedure did not report any difference in FEV-1 or in the frequency of emergency department visits or hospital admissions, between the bronchial thermoplasty group and the control group (Thompson, et al). Overall, the peer-reviewed medical literature indicates the requested bronchial thermoplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the requested procedure 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: Experimental
Decision: Overturned

Summary Reviewer 3


The parent of a four-year-old male enrollee has requested reimbursement for FirstStepDx Plus dated 5/12/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees autism spectrum disorder. The physician reviewer found the clinical utility of CMA and Fragile X testing is well established in the medical literature. Both CMA and Fragile X are considered first-line tests for patients with developmental delays and autism spectrum disorders according to the American College of Medical Genetics (Schaefer, et al). These tests provide both a unifying diagnosis, as well as clinically actionable information. Coulter and colleagues performed a study of patients with developmental delay, intellectual disability, autism spectrum disorders and congenital anomalies in order to determine the proportion of cases where abnormal CMA results impacted recommendations for clinical action. Among the 1,792 patients reviewed, 13.1% had clinically relevant results, either abnormal 7.3% or variants of possible significance (VPS) 5.8%. When an abnormal result was identified, a recommendation for clinical action was made 54% of the time and 34% of the time for VPS. Findings in this study demonstrated that CMA results influenced medical care in the majority of patients by precipitating medical referrals, diagnostic imaging, or specific laboratory testing supporting the use of CMA as a clinically useful diagnostic test. Recognition of Fragile X, much like copy number variants in CMA testing is clinically relevant for several reasons. This diagnosis allows for the routine evaluation of seizures, heart problems and vision problems.  It is also important to note that a diagnosis of Fragile X syndrome allows families to better understand recurrence risk in future pregnancies. For the reasons provided, the FirstStepDx Plus performed on 5/12/16 was 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 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 38-year-old male enrollee has requested reimbursement for the homocysteine testing provided on 9/5/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees anemia. The physician reviewer found that Homocysteine was performed as part of this patients anemia work-up, specifically as a companion test to vitamin B12 level along with methylmalonic acid. Measurement of the serum concentrations of the metabolic intermediaries homocysteine and methylmalonic acid can be more sensitive for the diagnosis of vitamin B12 deficiencies than serum vitamin levels alone (Lindenbaum, et al). If concentrations of both metabolites are increased, vitamin B12 deficiency is confirmed, with a sensitivity and specificity of 94% and 99%, respectively (Savage, et al). Consistent with this support, the homocysteine testing provided on 9/5/14 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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 
 
The parent of a seven-year-old female enrollee has requested authorization and coverage for 
Xeljanz 5 mg tablet. The Health Insurer has denied this request and reported that the requested 
medication is investigational for the treatment of the enrollees alopecia. The physician reviewer 
found that the U.S. Food and Drug Administration (FDA) approves the use of one Janus kinase 
(JAK) inhibitor, Olumiant (generic name baricitinib), for the treatment of adult patients with 
severe alopecia areata. Pediatric-onset alopecia areata, including alopecia universalis, tends to 
be more severe and carries a worse prognosis than adult-onset disease. While there are no FDA 
approved treatments for alopecia areata in pediatric patients, current medical literature supports 
the use of oral JAK inhibitors, such as Xeljanz, as resulting in an improvement of Severity of 
Alopecia Tool (SALT) scores. Kennedy Crispin and colleagues report that tofacitinib is a safe and 
effective treatment for severe alopecia areata. Toussi and colleagues note that alopecia areata 
has substantial psychosocial impact on patients and results in reduced health-related quality of 
life, which should be addressed as an active part of treatment. In this case, given the patients 
response to Xeljanz, including hair regrowth and improvement of psychiatric comorbidities, the 
requested medication is likely to be more beneficial than the several other treatments that she 
has already tried and failed. Therefore, Xeljanz 5 mg tablet 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 63-year-old female enrollee has requested authorization and coverage for an iris prosthesis. 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 records support the requested services in this patientas case. There is evidence in the medical literature that the device is safe and effective. Since traumatic aniridia is not a widespread phenomenon, there are not robust clinical trials for such a device. Nonetheless, there are numerous smaller trials and investigational studies for this device that have demonstrated safety and efficacy for treating this disease. Treatment with contact lenses, corneal tattooing, or tinted spectacles are not adequate treatments for the patientas disease. Therefore, the requested iris prosthesis is likely to be more beneficial for the treatment of this patient than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 60-year-old male enrollee has requested reimbursement for platelet-rich plasma injections performed on 3/11/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees plantar fasciitis. The physician reviewer found that the use of platelet-rich plasma injections for tendon and ligament injuries show no statistically significant benefit.  For muscle injury, evidence is also insufficient, conflicting, or poor, as it is for the treatment of osteoarthritis and other joint pathologies.  For plantar fasciitis, the evidence is insufficient and conflicting, and demonstrates an incomplete assessment of net benefit versus harm.  Therefore, additional studies and research are warranted.  In a study by De Vos and colleagues, a randomized controlled trial was done on patients with chronic Achilles tendinopathy.  The patients were equally divided to receive either platelet-rich plasma injections or saline injections.  The study showed no statistically significant differences in pain or activity levels between the two groups.  Sanchez and colleagues did a retrospective, case controlled study of 12 athletes who underwent surgical repair of a complete Achilles tendon tear to see if platelet-rich plasma promotes healing and functional recovery.  The authors concluded that platelet-rich plasma may enhance healing and functional recovery, but further studies are needed to verify outcomes.  Based upon the information set forth above, the services at issue were 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: Experimental
Decision: Upheld

Summary Reviewer 2


The parent of a 13-year-old female enrollee has requested reimbursement for homocysteine testing performed on 12/31/15. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees behavioral health condition. The physician reviewer found the homocysteine testing has been used to assess vitamin B12 deficiency, lack of folic acid in the diet, hypothyroidism, certain cancers and Alzheimers disease.  In this clinical setting, the patients parent and her provider requested the test to assist in the treatment plan for the patients ADHD. In order to render a diagnosis of ADHD there must be symptoms of inattention and/or hyperactivity-impulsivity that are chronic or long-lasting, impair the persons functioning, and cause the person to fall behind normal development for his or her age. Evidence based studies are lacking in correlating homocysteine levels with ADHD. Due to the lack of scientific data demonstrating or correlating homocysteine levels to ADHD and its treatment, the test at issue was not likely a better marker than available standard therapies. Based upon the information set forth above, the requested 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 2

A 28-year-old male enrollee has requested reimbursement for ColonSentry testing (CPT code 81479) performed on 10/23/14.  The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found the ColonSentry test is typically performed to help patients decide on whether or not a colonoscopy may be indicated. The ColonSentry test does not replace colonoscopy as the gold standard for colon cancer screening. In this case, the patient has undergone surveillance colonoscopy and the case file does not show any contraindication to future procedures. As such, the ColonSentry testing (CPT code 81479) performed on 10/23/14 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 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 60-year-old male enrollee has requested authorization and coverage for verapamil. 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 there is a lack of support for the requested medication in this clinical setting. The current literature is challenging to interpret, given the varied patient inclusion criteria, including the focus on patients in the active disease stage with dynamic and evolving symptoms, varied treatment protocols, and the conflicting findings reported. Most studies include patients with at least 30 degree curvature. Many patients with lesser curvature do not have difficulty with penetration and can be managed by observation. In this patients case, the documentation does not support difficulty in penetration due to degree of curvature. Per the records, he was noted to have 15 degree curvature. As such, the use of verapamil would not be considered a clinically appropriate and generally accepted standard of care for the management of this patient. Therefore, verapamil is not likely to be more effective than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 56-year-old female enrollee has requested authorization and coverage for Xadago. 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 current medical evidence supports the requested medication in this clinical setting. Bette and colleagues noted in large clinical trials of patients with early Parkinsons disease on a single dopamine agonist, Xadago administered orally at a dose of 100 mg daily improved overall motor function as measured by Unified Parkinsons Disease Rating Scale (UPDRS) part III total score. Safinamide is generally well-tolerated and safe, with few to no treatment-related adverse events. Safinamide does not cause new or worsening dyskinesia and may be able to reduce this symptom in patients reporting it at baseline. In this patients case, the records document early onset Parkinsons disease. Long duration use of carbidopa/levodopa therapy can lead to the development of motor side effects. The patient is likely to benefit from the requested medication. Therefore, Xadago is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1
A 51-year-old female enrollee has requested reimbursement for the MammaPrint genetic test provided on 2/3/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees left breast carcinoma. The physician reviewer found that the decision to use adjuvant chemotherapy is typically based on the pathologic details of an individual patients breast cancer as well as genetic analyses in certain situations. The OncotypeDX and MammaPrint gene assays can help determine whether an individual patient is at low or high risk of recurrence. Patients at high risk are often recommended to receive adjuvant chemotherapy (Cardoso, et al). In this case, the OncotypeDX assay placed this patient in an intermediate risk category. In this clinical setting, the provider will likely recommend adjuvant chemotherapy given the positive node and intermediate results on OncotypeDX. In view of her nodal positivity, the MammaPrint genetic test provided on 2/3/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 23-year-old female enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 2/6/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found that the testing at issue was likely to be more effective for this patient than other available options. Therapeutic drug monitoring for infliximab and antibodies to the drug is appropriate for optimizing the treatment of the patients who are being treated with Remicade. The loss of response to infliximab can be due to subtherapeutic infliximab levels or the presence of antibodies to infliximab, and performing this assay can be very useful in the management of the patients with ulcerative colitis who are being treated with infliximab. The concept of dose adjustment, based on drug levels, has several potential benefits, one of which is that providers could not only increase drug doses in patients with subtherapeutic drug levels, but could also reduce drug doses in patients with supertherapeutic levels, thereby making the treatment safe for the patients. Therefore, measuring both IFX and ATI concentrations may help guide patient management, optimize care, prevent complications, and reduce long-term morbidity and mortality from complications. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 52-year-old male enrollee has requested reimbursement for gene testing (gene expression profiling) performed on 10/31/18. 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 this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state that 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. This patients pathology indicates low risk disease. Therefore, gene testing (gene expression profiling) performed on 10/31/18 was not likely to have been more beneficial than other methods of evaluating this patient.