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

Summary Reviewer 

An 18-year-old male enrollee has requested reimbursement for residential mental health treatment for children and adolescents provided from 11/16/17 through 1/04/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2. The medical records indicate that the patient was not actively suicidal at any time, although he had recent passive suicidal ideation without intent to harm himself. With regards to functional status, the records support a score of 2. The patient has had some issues with level of function that were sporadic nature. He showed intact activities of daily living. In terms of comorbidity, the records support a score of 1. The patient does not have active medical problems or substance use. With regards to level of stress of the recovery environment, the records support a score of 2. There was no indication of an unsafe home environment. In terms of level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 3. It appears that the patient has had minimal prior treatment and was cooperative in the residential treatment center program at issue. In terms of acceptance and engagement, the records support a score of 2. The patient actively participated in therapy on admission. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient had a composite score of 16.  This score correlates with intensive outpatient services. Therefore, residential mental health treatment for children and adolescents provided from 11/16/17 through 1/04/18 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 66-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Expression Assay provided on 10/12/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. However, there is a lack of peer-reviewed published studies confirming the role of DecisionDx-Melanoma Gene Assay in this clinical setting. All told, the DecisionDx-Melanoma Gene Assay performed on 10/12/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was 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 44-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 7/28/21. The Health Insurer has denied this request and reported that the services 
at issue were investigational for the evaluation of the enrollees melanoma. The physician 
reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous 
melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for 
those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be 
amenable to excision but this suggests a high risk for the development of metastatic disease in 
the future. Such patients may be observed or treated with interferon-alpha. The data on 
DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node 
biopsy. There has also been some lack of consistency between various genes being used as 
biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the 
treatment algorithm beyond standard staging techniques. This is also the consensus opinion of 
the  National  Comprehensive  Cancer  Network  guidelines.  Therefore,  DecisionDx-Melanoma 
testing performed on 7/28/21 was not likely to have been more beneficial for evaluation of the 
patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 61-year-old female enrollee has requested reimbursement for Collagen Type 1 C-telopeptide blood test that was performed on 11/21/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees post-menopausal osteoporosis. The physician reviewer found per the National Osteoporosis Foundation guidelines, biochemical markers of bone turnover may predict the following: risk of fracture independently of bone density in untreated patients; rapidity of bone loss in untreated patients; the extent of fracture risk reduction when repeated after 36 months of treatment with Food and Drug Administration (FDA) approved therapies; help determine adequacy of patient compliance and persistence with osteoporosis therapy; and help determine duration when and if medication should be restarted.In this patient, the biochemical marker of bone turnover Collagen Type 1 C-telopeptide, aids the physician in risk assessment and serves as an additional monitoring tool when treatment is initiated (Cosman et al and Burch et al). The change in biochemical markers can be seen sooner than the expected change in bone mineral density. The standard of care is to normally order this test as part of the assessment of patient compliance and effect of medication on bone turnover. It is widely used by endocrinologists and experts in osteoporosis management to assess the effect of therapy as delineated above. This test, Collagen Type 1 C-telopeptide, was appropriately ordered for this patient as part of her osteoporosis management.Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 54-year-old male enrollee has requested reimbursement for the DecisionDx melanoma assay provided on 2/5/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the DecisionDx melanoma assay tests the tissue genetics of the melanoma to help stratify whether a thin melanoma is high risk for metastasis. The DecisionDx test has shown some impressive accuracy in thin melanomas like this patients. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Further, there is a paucity of literature to support its use in the care of patients with thin melanomas to effect health outcomes. The test is currently not standard of care, has not been demonstrated to provide a beneficial effect on health outcomes, and is not recommended by the NCCN guidelines. Overall, there is not enough published data to support its routine use. There needs to be clinical trials to determine the utility of the results of the test. Since this test does not provide a benefit more than established tests on outcomes, the DecisionDx melanoma assay provided on 2/5/16 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 3


A 51-year-old male enrollee has requested reimbursement for DecisionDX testing provided on 10/6/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees uveal melanoma.  The physician reviewer found there is convincing scientific evidence that genetic testing of uveal melanoma tumor can stratify the tumors into high and low risk for systemic metastasis (Field and Harbour). The key questions are whether having this information is needed for an individual patient and whether it alters the course of treatment. Currently, this test is part of the standard of care in these patients in this clinical setting (Shields and Shields). Given this support, the DecisionDX testing provided on 10/6/14 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: Upheld

Summary Reviewer 1

A 61-year-old female enrollee has requested authorization and coverage for endoscopic anti-reflux procedure (LINX). The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that there is sufficient support for the requested services in this patients case.  The U.S. Food and Drug Administration has approved the LINX reflux management system for lower esophageal sphincter augmentation. Appropriate candidates for the procedure include patients with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate GERD and a hiatal hernia less than 3 cm. This patient meets those specific criteria and in addition has a documented episode of aspiration pneumonia perhaps from a severe reflux event. As such, the medical evidence supports the efficacy of the requested procedure in this clinical setting.  Accordingly, the requested endoscopic anti-reflux procedure (LINX) is likely to be more effective than the standard options for treatment of this patients medical condition. Therefore, for the reasons stated above, the requested procedure 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 1

A 55-year-old male enrollee has requested reimbursement for CPT code 81479 provided on 12/21/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there currently are three major approaches to the management of localized prostate cancer. These include surgical prostatectomy, radiation therapy, or active surveillance with no specific treatment given. Recommendations as to these options are based on risk stratification, which is a process that takes into account patient factors, prostate-specific antigen level, clinical stage, Gleason grade, and the percent of involvement of the cores. Using this methodology, this patient falls into the very low risk category. Generally, active surveillance is recommended for such patients. Oncotype DX testing is an analysis of the expression of 12 genes in an individuals cancer cells. It then classifies that cancer into various risk categories of cancer progression. Such analyses appear useful in patients undergoing prostatectomy and in other risk categories. However, there is a lack of support for the use of this testing in patients in the very low risk category, such as this patient. Therefore, CPT code 81479 provided on 12/21/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 62-year-old male enrollee has requested reimbursement for laboratory services provided on 9/06/18. 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 prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Berger and colleagues reported on its use in 156 cases, but there was insufficient follow-up to determine the actual value of the assay. It is not clear how the ten-year Balch data compares to the five-year DecisionDx-Melanoma data. Furthermore, it is not clear if the assay can be used to make clinical decisions. Therefore, laboratory services provided on 9/06/18 were not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 49-year-old transgender female enrollee has requested reimbursement for breast augmentation provided on 3/26/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. This patient had well-documented gender dysphoria related to masculine features of her body. The records documented social anxiety and depression. Feminizing mammoplasty under these circumstances is medically necessary for the treatment of gender dysphoria. World Professional Association for Transgender Health (WPATH) criteria for surgery state that surgical procedures for patients with gender dysphoria may include augmentation mammoplasty, genital surgery and other interventions, such as facial feminization surgery, lipofilling and thyroid cartilage reduction. The current medical evidence supports the services at issue in this clinical setting. Therefore, breast augmentation provided on 3/26/18 was medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 44-year-old female enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees sacroiliac joint pain. The physician reviewer found that this patient presents with chronic left sacroiliac joint pain following childbirth, and chronic low back and left leg pain and paresthesias. She has been diagnosed with left sacroiliac joint pain, sacroiliitis, and sacroiliac joint dysfunction. She has reportedly failed extensive conservative treatment options, including physical therapy, home exercise program, chiropractic care, bracing, and nonsteroidal anti-inflammatory drugs. On 4/05/18, left sacroiliac joint corticosteroid injection reduced pain from grade 6/10 to 4/10 (33%) for less than one week. There is no imaging study presented to evidence sacroiliac joint spondyloarthropathy, degenerative sacroiliitis, or sacroiliac joint disruption. Current evidence-based guidelines and literature support minimally invasive sacroiliac joint fusion for patients with sacroiliac joint dysfunction due to degenerative sacroiliitis or sacroiliac joint disruption. However, current evidence-based guidelines do not support sacroiliac joint fusion for mechanical low back pain, non-specific low back pain, sacroiliac joint disruption (in the absence of major pelvic fracture), degenerative sacroiliitis or sacroiliac joint osteoarthritis. In this case, there is no clear evidence of a condition for which sacroiliac joint fusion is supported. Additionally, diagnostic injection response does not meet the standards of at least 75% decrease in pain. Therefore, sacroiliac joint fusion 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 35-year-old female enrollee has requested reimbursement for arthroscopy surgery provided on 11/21/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient presented with chronic significant right hip pain with associated popping, clicking, and snapping, and repeated dislocations. Functional limitations were documented in activities of daily living. Clinical examination findings were consistent with radiographic evidence of femoroacetabular impingement and imaging findings of labral cartilaginous junctional delamination, confirmed at the time of arthroscopic examination. She had a history of bilateral hip dysplasia and no evidence of significant degenerative changes. Detailed evidence of long-term comprehensive nonoperative treatment and failure was submitted. She underwent complex right hip arthroscopic surgery with acetabuloplasty, femoroplasty, labral cartilaginous junctional refixation after abrasion chondroplasty, microfracture, synovectomy and capsular plication on 11/21/18. Current evidence-based medical literature supports this surgical intervention in this clinical scenario. Therefore, the arthroscopic surgery provided on 11/21/18 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 46-year-old female enrollee has requested authorization and coverage for Epclusa. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive, genotype 2 patients, based on clinical trials which showed a 99% cure rate and superiority to Sovaldi with ribavirin. A delay in treatment may result in decreased survival. All told, Epclusa is medically necessary in this patients case. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

The patient is a 46-year-old female with a history of right hip pain. The patients hip pain has not responded to conservative treatment in addition to revision arthroscopic labral debridement, iliopsoas bursectomy, synovectomy, lysis of adhesions, and capsular release. The patient has requested authorization and coverage for AmnioFix injection. The Health Insurer has denied this request indicating that the requested service is considered investigational. While intraarticular stem cell injections for osteoarthritis have been evaluated in clinical trials, it is not currently a standard treatment for hip osteoarthritis. In addition, there is a lack of data regarding the clinical safety including the risk of complications after surgery, compatibility of donor stem cells, and long-term effectiveness. There is an insufficient amount of clinical data demonstrating superiority of amniotic fluid injections when compared with pharmacological treatments for osteoarthritis. Given the adverse biomechanical nature of a dysplastic hip, injections of amniotic stem cells, or stem cells of any derivative, are not likely to provide any lasting relief. Thus, the requested AmnioFix injection 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, the requested service 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 1


The parent of a two-year-old male enrollee has requested reimbursement for FirstStepDX Plus chromosomal microarray analysis.  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 array-based comparative genomic hybridization has become standard of care to investigate children with developmental delay, intellectual disability, autism spectrum disorders or congenital anomalies. Until recently, it was a diagnostic test that was employed when the first-line investigation of karyotype (chromosome analysis) returned normal; over the last several years it has emerged as a first-line investigation.  This test has become an important and mainstream tool in the practice of clinical genetics. Its diagnostic utility had been convincingly demonstrated.  Data have now emerged showing that actionable findings from chromosomal microarray justify its use. In sum, FirstStepDX Plus chromosomal microarray analysis was likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.