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

Summary Reviewer 

The patient is a 43-year-old male with a history of bilateral squamous cell carcinoma of his oropharynx, cT3N0M0 stage II left tonsillar cancer and cT1N0M0 stage I right tonsillar cancer. The patient has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are 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 submitted documentation supports the medical necessity of the requested services. It is appropriate to spare the more superficial parotid gland, while maintaining coverage of the deep parotid/level II nodal region, as the treating provider has demonstrated in the plan comparison. The provider has shown that the use of photon-based intensity modulated radiation therapy would be associated with an excessive risk for parotid gland injury, resulting in xerostomia that would put the patient at an unacceptable risk for complications, such as swallowing dysfunction and dental caries. The proton radiation plan was able to significantly reduce the parotid exposure to within known safe tolerance limits, thereby minimizing this risk for high-grade radiation-induced morbidity. Proton radiation is supported by the American Society for Radiation Oncology (ASTRO) Model Policy and National Comprehensive Cancer Network guidelines in this setting, as the provider has shown that photon-based radiotherapy cannot be delivered with adequate safety/precision. Therefore, the requested proton beam radiation therapy is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 62-year-old female enrollee has requested reimbursement for the ThyGenX Thyroid Oncogene Panel testing provided on 11/18/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees thyroid nodule. The physician reviewer found that while a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate (Alexander, et al). Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign (Miller, et al). The ThyGenX analyzes a panel of DNA mutations and RNA translocation fusion markers to assess the risk of malignancy with good negative and positive predictive value thereby obviating the need for unnecessary surgery. Currently, there is adequate data supporting the ThyGenX Thyroid Oncogene Panel testing provided on 11/18/15 as 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 3

A 54-year-old male enrollee has requested reimbursement for high-intensity focused ultrasound (HIFU) performed on 6/28/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that HIFU for prostate cancer is relatively new procedure. The U.S. Food and Drug Administration (FDA) has approved this procedure to be safe for treatment of prostate ablation. However, there is no specific indication for treatment of prostate cancer. The safety and efficacy of this treatment is currently being evaluated. The medical evidence has not demonstrated that this form of treatment is superior to conventional treatment options. Thus, HIFU provided on 6/28/16 was not likely to have been superior over other treatment modalities. 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: Overturned

Summary Reviewer 1

A 52-year-old female enrollee has requested authorization and coverage for matrix-assisted autologous chondrocyte implantation (MACI) procedure. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees knee pain. The physician reviewer found that there is a lack of support for the requested services in this clinical setting. In this case, the requested MACI procedure is not recommended or supported by high-quality literature for this patients condition. This procedure is not indicated for lesions involving the patellar cartilage or for bipolar patellofemoral lesions. Additionally, this procedure is not indicated in the presence of patellofemoral malalignment.  There is lack of data to support the efficacy of MACI in these clinical situations, which have all been documented as being present based on the submitted operative report. Thus, the requested MACI procedure is not likely to be superior over other treatment options. Based upon the information set forth 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: Experimental
Decision: Overturned

Summary Reviewer 1
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 desired procedure is a minimally invasive radiofrequency ablation treatment that reduces fibroid-related symptoms by reducing fibroid volume. The procedure is performed through a laparoscopic approach. Alternative standard therapy to the procedure includes more aggressive interventions, such as hysterectomy or myomectomy. Interventional radiology embolization procedures are only successful in a certain patient population with fibroids in specific locations. The procedure is done as an outpatient basis, with return to normal activity within approximately one week. Using ultrasound guidance to identify the fibroid, a conductive needle array punctures the fibroid and transmits radiofrequency energy, which causes coagulative necrosis. An ultrasound probe is used to monitor the tissue effect until the bulk of the fibroid is treated. Over subsequent months, fibroids are reabsorbed, with a decrease in fibroid volume and a resultant reduction in fibroid-related symptoms. This is directed therapy and allows for treatment in the proper candidate within a minimally invasive surgical approach. The medical evidence supports the requested services in this clinical setting. Therefore, CPT 58674 (Acessa procedure - laparoscopic radiofrequency ablation) is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 37-year-old male enrollee has requested reimbursement and prospective authorization and coverage for assay for calprotectin fecal laboratory performed on 10/28/16 and ongoing. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the role of fecal calprotectin has been extensively studied in many areas of inflammatory bowel disease (IBD) patients management. There is emerging evidence that fecal calprotectin is a useful surrogate marker of inflammation in the post-operative setting, as it correlates with the presence and severity of endoscopic recurrence according to Rutgeerts score and can predict the subsequent clinical recurrence and response to therapy in CD patients. There is sufficient medical literature showing the usefulness of following fecal calprotectin levels serially. All told, the assay for calprotectin fecal laboratory performed on 10/28/16 and ongoing was and is 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 and is 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 2 
A 23-year-old female enrollee has requested reimbursement for intraoperative monitoring on 
7/25/22. The Health Insurer has denied this request and reported that the service at issue was 
investigational for the treatment of the enrollees spastic quadriparesis secondary to cerebral palsy 
and spastic dislocation of the right hip. The physician reviewer found that in a review of the 
intraoperative monitoring records of 40 hip periacetabular osteotomies, Novais and colleagues 
found that abnormal recording alerts notified the surgeon in six cases, allowing the surgeon to alter 
the surgical plan and take steps to avert serious permanent sciatic nerve injury. In a case series of 
10 patients, Overzet and colleagues identified changes in 36% of the cases, due to leg lengthening 
procedures, that allowed the surgeon to take corrective procedures to avoid permanent injury. In a 
systematic review, Murena and colleagues concluded, There is general agreement in recognizing 
a role for intraoperative nerve monitoring to define the critical maneuvers, positions or pathologies 
that could lead to sciatic nerve intraoperative damage. In this clinical setting, given the complex 
nature of this patients severe hip deformity and osteotomy, the service at issue was likely to have 
provided more benefit for this patient than standard care.  Therefore, intraoperative monitoring on 
7/25/22 was likely to have been more beneficial for treatment of the patients condition than any 
available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 58-year-old female enrollee has requested reimbursement for the DecisionDX uveal melanoma (UM) multigene assay performed on 4/10/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees intraocular choroidal melanoma of the left eye. The physician reviewer found that there is a lack of evidence-based medical studies that support the superiority of DecisionDX assay over standard testing options for the evaluation of uveal melanoma in this clinical setting. While there are some studies that show genomic testing can lead to more frequent evaluations for metastasis, there is still is no approved adjuvant therapy for the treatment of uveal melanoma. Moreover, it has not been shown to predict response to adjuvant therapy. In summary, the DecisionDX uveal melanoma multigene assay performed on 4/10/15 was not likely to have led to greater benefit for the evaluation of this patient than other standard treatment options. Based upon the information set forth above, the service 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 42-year-old female enrollee has requested authorization and coverage for disc fusion. 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 the submitted documentation supports the medical necessity of the services at issue. Anterior lumbar interbody fusion is associated with higher fusion rates compared with posterolateral lumbar fusion in patients with degenerative changes of the lumbar spine, including those with instability.  There is moderate evidence that for lumbar degenerative disc disease without instability, a standalone anterior lumbar interbody fusion has better clinical outcomes than the anterior lumbar interbody fusion plus instrumented open posterior lumbar fusion. With regard to the type of interbody spacer used, frozen allograft is associated with lower pseudarthrosis rates compared with freeze-dried allograft. Based on these guidelines, the requested anterior lumbar interbody fusion procedure is likely to be beneficial for this patients severely symptomatic degenerative disc disease with a 4 mm protrusion at L5-S1 that did not respond to nonoperative treatment. Therefore, the requested 63077, 22558 and 22845 are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 46-year-old female enrollee has requested reimbursement for CPT code 84999 performed on 1/12/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the DecisionDx-Melanoma testing has been developed in patients with stage I and II cutaneous melanoma. However, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. 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 according to published data available. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate benign from malignant neoplasms, or melanomas at low versus high risk for metastasis, routine genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. In sum, CPT code 84999 performed on 1/12/17 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: Overturned

Summary Reviewer 3


A 57-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 11/24/15.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. 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 (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breast tissue was extremely dense.  While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis performed on 11/24/15 was likely to have been superior over other methods of evaluating this patient.  Based upon the information set forth above, the service 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 3 
A 27-year-old female insured has requested authorization and coverage for Besremi 500 mcg/mL 
syringe. A review of the record indicates the insured is currently pregnant and has a history of 
essential thrombocythemia. The Health Insurer indicates the requested treatment is considered 
investigational for the treatment of the insureds medical condition. Therefore, the Health Insurer 
has denied coverage for the requested treatment. This denial is the subject of this appeal and 
determination. The physician reviewer found that the use of aspirin and interferon has been 
associated with increased numbers of live births without significant maternal or fetal adverse 
effects, according to current data from the peer-reviewed medical literature. One meta-analysis 
and review of the literature included 767 patients and 1,210 pregnancies from 22 studies on patients 
with myeloproliferative neoplasms, most of whom had essential thrombocythemia (Maze, et al.). 
The authors found that moderate-quality evidence suggests that aspirin or interferon is associated 
with higher odds of live birth in pregnant women with myeloproliferative disorder. Although 
Pegasys and Besremi are both pegylated interferon (peginterferon) alfa-2a, Besremi is better 
tolerated with fewer injections and it has been shown to be safe during pregnancy. All told, the 
requested Besremi 500 mcg/mL syringe is likely to be more beneficial for the treatment of the 
patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a nine-year-old female enrollee has requested authorization and coverage for chromosomal microarray analysis.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found that Microarray is a first-line test in the evaluation of children with intellectual disability/developmental delay, autism spectrum disorder, or multiple congenital anomalies. This patient falls into a category of patient for whom microarray is recommended as a first line investigation. Microarray technology has evolved over the years, initially being done using bacterial artificial chromosomes (BAC) and now being done with oligonucleotides and single nucleotide polymorphisms. The patient has previously had a microarray, but the results were not provided and the details of the methodology used are not given. In order to determine if a chromosomal microarray analysis is superior to what was done previously, a comparison of the methodologies is needed.  Additionally, it is noted that the initial microarray showed a maternally-inherited chromosome 16 deletion which was interpreted as nonsignificant. Interpretation of a chromosomal microarray finding may change over time as new information regarding significance of copy number variations becomes available (Palmer, et al). Therefore, the appropriate next step is to have this patients prior microarray results reviewed by a clinical geneticist who can re-evaluate the medical literature associated with the chromosome 16 deletion to determine if there has been a change in interpretation of pathogenicity, and decide, based on this information and comparing the methodology of the previous microarray and the proposed new testing, whether a new study is needed. 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 1 
 
A 75-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 5/26/21. 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 according to specific 
American  Joint  cancer  Committee  (AJCC)  melanoma  stage  requires  further  prospective 
investigation in large, contemporary datasets of unselected patients. Prognostic 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 early stage 
melanoma and a higher proportion of false-positive results, GEP testing should not guide clinical 
decision-making in this subgroup. 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. Therefore, DecisionDx-Melanoma testing performed on 
5/26/21 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 35-year-old male enrollee has requested authorization and coverage for bariatric surgery and one day inpatient admission. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees morbid obesity. The physician reviewer found that this patient meets all nationally accepted criteria for bariatric surgery including the American Society for Metabolic and Bariatric Surgery. This patient is an adult that is morbidly obese with a BMI of 52 kg/m2. The patient has failed dietary efforts including more than six months of supervised weight loss. The patient completed a comprehensive multidisciplinary evaluation that did not reveal any obvious dietary, psychological or medical barriers to surgery. The patient has no correctable causes of obesity and has demonstrated ongoing reliable participation in preparatory program. The provider as included an attestation regarding compliance to a long-term program with diet, multidisciplinary program, lifestyle changes and follow-up. Given these findings, the requested bariatric surgery and one day inpatient admission are supported as medically necessary for treatment of this patients medical condition. Based on the foregoing, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.