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

Summary Reviewer 3
A 52-year-old male enrollee has requested reimbursement for proton beam therapy provided from October through December 2016. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees nasopharyngeal carcinoma. The physician reviewer found that based on review of available data, proton beam therapy in the treatment of nasopharyngeal carcinoma is superior to the standard alternatives available.
While there are no randomized trials evaluating the use of proton beam therapy for nasopharyngeal carcinomas, its Bragg Peak, proton beam therapy will always appear dosimetrically superior (Lewis 2016). For any given site, whether or not this dosimetric benefit translates into a clinical benefit is uncertain, but such a benefit exists for nasopharyngeal carcinoma. The treatment of skull-based tumors is a well-accepted use of proton therapy. It is the prototypical site used to demonstrate the ability of proton therapy to spare adjacent cranial nerves in a tight space to a high precision. The most common histology of skull-based tumors are chordomas and chondrosarcomas. According to the ASTRO Model Policy on Proton Beam Therapy, on the basis of [the above] medical necessity requirements and published clinical data, disease sites that frequently support the use of PBT include  tumors that approach or are located at the base of skull, including but not limited to chordoma and chondrosarcomas. Due to the fact that the typical nasopharyngeal carcinoma radiation field includes the base of skull by definition (RTOG 0615), and that the dose required to treat nasopharyngeal cancer is higher than needed for a chordoma, proton therapy would also be beneficial for the treatment of nasopharyngeal cancer. Additionally, the optic nerves and chiasm are typically adjacent to the treatment volume for nasopharyngeal carcinoma. These structures typically limit the nasopharynx from receiving the full prescribed dose of radiotherapy, whereas proton beam therapy would allow full treatment of these areas. Based on the above, proton beam therapy provided from October through December 2016  was the superior modality for the treatment of  this patients medical condition. Therefore, for the reasons stated above, the services at issue were likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 59-year-old female enrollee has requested authorization and coverage for Viekira Pak. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus (HCV). The physician reviewer found that review of the submitted documentation establishes the medical necessity of the requested medication. According to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for HCV treatment Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. AASLD/IDSA guidelines further adding that The goal of treatment of HCV-infected persons is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. Additionally, the study by Ferenci and colleagues concluded that Twelve weeks of treatment with ABT-450/r-ombitasvir and dasabuvir without ribavirin was associated with high rates of sustained virologic response among previously untreated patients with HCV genotype 1 infection. Rates of virologic failure were higher without ribavirin than with ribavirin among patients with genotype 1a infection but not among those with genotype 1b infection. Therefore, based upon the peer reviewed literature cited above, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 42-year-old male who has requested authorization and coverage for Oxbryta 500 
mg. The patient has requested authorization and coverage for Oxbryta 500 mg. The physician 
reviewer found that the submitted documentation supports the requested medication in this 
clinical setting. Voxelotor (Oxbryta) has been approved by the U.S. Food and Drug Administration 
for the treatment of sickle cell disease in adults and pediatric patients who are four years of age 
or older. Adakveo and Endari are used to decrease the incidence of vaso-occlusive events. This 
patients main issue is fatigue. Voxelotor may be considered in patients whose morbidity is from 
severe anemia (hemoglobin less than or equal to 6.5 g/dL), excessive fatigue, poor quality of life, 
and decreased Clinical Global Impression of Change (CGI-C) score. The other drugs are not used 
for fatigue. The use of the requested medication is supported by phase III clinical trials. Therefore, 
Oxbryta 500 mg is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 60-year-old male enrollee has requested reimbursement for inpatient services (telemetry level of care) provided from 4/04/19 through 4/06/19. 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 the patient had known coronary artery disease and multiple prior interventions. He was initially scheduled for elective catheterization when he presented to the outpatient office with low effort angina, and his medical regimen was appropriately adjusted at that time. However, in the subsequent days, he developed rest angina and was diagnosed with acute coronary syndrome. Patients presenting with rest angina and known complex coronary artery disease require hospitalization to rule out myocardial infarction, have cardiac telemetry monitoring and then are referred for cardiac catheterization and potential revascularization. Initially, the plan was for elective catheterization. However, the patients symptoms progressed rapidly, and he presented with an acute coronary syndrome in the setting of prior known severe coronary artery disease. Admission for acute coronary syndrome to rule out myocardial infarction, telemetry monitor, adjust his acute medical regimen and undergo subsequent catheterization and revascularization was medically appropriate and within the current standard of care. Therefore, inpatient services (telemetry level of care) provided from 4/04/19 through 4/06/19 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 62-year-old male enrollee has requested reimbursement for gene testing for prostate cancer performed on 4/21/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features such as the grade of tumor and PSA level. This helps guide the most appropriate therapy for patients taking into account their age and co-morbidities because many patients will not require therapy and may be observed without any intervention. The important features to recognize are Gleason score and PSA but these are imperfect and better prognostic biomarkers are needed. There are no robust biomarkers that can predict which cancers should be observed and which should be aggressively treated by radiation or surgery. The Prolaris test is an analysis of expression of genes (Cuzick, et al, 2012). It has been extensively tested retrospectively on a large cohort of prostate cancer patients (Cuzick, et al, 2011). It was also applied on another cohort and found to be predictive of prostate cancer aggressiveness (Cuzick, et al, 2014). The provider in this case had a reasonable discussion with the patient regarding treatment options and the Prolaris data may assist him and the patient to determine with the best treatment option. As such, the gene testing for prostate cancer performed on 4/21/15 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 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 2


A 21-year-old male enrollee has requested authorization and coverage for LINX reflux management system.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the current medical evidence supports the requested services in this clinical setting.  LINX is a minimally invasive anti-reflux procedure that has been approved by the U.S. Food and Drug Administration.  LINX has been shown to be as effective as surgery, and is less invasive.  Additionally, LINX is potentially reversible, with less adverse effects.  In sum, the requested LINX reflux management system is likely to be more efficacious than other treatment options.  Based upon the information set forth above, the requested services are 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 59-year-old female enrollee has requested reimbursement for Afirma Gene Expression Classifier assay performed on 10/12/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees thyroid nodule. The physician reviewer found the medical evidence supports the services at issue in this clinical setting.  The cytopathology of the thyroid nodule was consistent with follicular lesion of undetermined significance.  The risk of malignancy is 5 to 15% in these nodules.  The newest 2015 American Thyroid Association guidelines indicate that for nodules with follicular lesion of undetermined significance cytology, investigations such as repeat fine needle aspiration or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with either surveillance or diagnostic surgery.  In this patients case, the services at issue assisted with treatment planning.  Thus, Afirma Gene Expression Classifier assay performed on 10/12/15 was 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 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 has requested authorization and coverage for 64568, 0466T and 95970. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea.  The physician reviewer found that this patient has requested implantation of hypoglossal nerve stimulation for her symptoms of obstructive sleep apnea. She previously was treated with CPAP therapy, but the patient became intolerant to the use of this device. Sleep study reports documented increasing symptoms of obstructive sleep apnea with apnea-hypopnea index at the moderate level of obstructive sleep apnea syndrome. Hypoglossal nerve stimulation therapy has been proven by the U.S. Food and Drug Administration (FDA) to be an effective modality of treatment of obstructive sleep apnea in patients with tongue-based obstruction. This patient did have evidence of some degree of tongue base obstruction based on sleep endoscopy procedure. Although this patient meets some of the criteria for implantation of upper airway stimulation, she has not undergone other methods of management.  Other surgical procedures have not been attempted, such as nasal turbinate reduction and/or nasal septal reconstruction.  These methods have been shown to improve tolerance to nasal CPAP therapy. Additionally, the patient may be a candidate for other traditional oropharyngeal surgery, such as uvulopalatopharyngoplasty with tonsillectomy, which may improve symptoms. Therefore, the requested services (64568, 0466T and 95970) are not likely to be of greater benefit than 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: Upheld

Summary Reviewer 1

A 23-year-old male enrollee requested authorization and coverage for E1399 (functional electrical stimulation cycle ergometer). The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of the enrollees medical condition. The physician reviewer found that the medical evidence has not established the superior efficacy of the requested device. There is a lack of proven significant health or functional benefit of exogenous neurostimulation therapy of paralyzed muscles using functional electrical stimulation cycle ergometry. There have been a number of small papers (case reports and series) published over the years providing some preliminary data suggesting possible benefits, but larger studies designed to evaluate the actual clinical efficacy of passive exercise such as functional electrical stimulation cycle ergometry in the setting of spinal cord injury have not been completed and published. While repeated bouts of exogenous neurostimulation of paralyzed muscle may potentially reverse muscle atrophy in paralyzed muscle, there is no significant health or functional benefit of this process in spinal cord injury because the muscle tissue that is gained or spared does not protect against pressure ulcers in a clinically relevant manner or provide other clinically or functionally relevant benefit. It does not obviate the need for pressure relief.  Passive cycling may be an option to provide passive range of motion therapy, e.g., to prevent contractures or mitigate spasticity, but this can also be performed independently or with caregiver assistance in a custodial fashion. The other purported benefits of passive cycling, such as improving cardiovascular function and bone density, have not been sufficiently investigated to allow conclusions related to clinically relevant outcomes. To date, the limited data that are available provide mixed results regarding health measures. With respect to bone health after spinal cord injury, there are insufficient data regarding clinically relevant outcomes related to the efficacy of this device. Therefore, E1399 (functional electrical stimulation cycle ergometer) is not likely to be superior over other available treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 31-year-old female enrollee has requested reimbursement for the collagen cross links, any method (CPT code 82523) provided on 1/10/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees left ankle pain status De Novo procedure for osteochondral lesion of the medial talar dome. The physician reviewer found that the use of collagen cross links and biochemical markers of bone turnover, are unproven and not considered part of the standard of care in this clinical setting. Other testing that was performed in this patients case should have been adequate to rule out a bone formation abnormality. As such, the collagen cross links, any method (CPT code 82523) provided on 1/10/17 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 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: Experimental
Decision: Upheld

Summary Reviewer 3

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 early breast cancer that is hormone receptor positive can be treated with tamoxifen alone in postmenopausal women. In that instance, there is a 15% chance of recurrence. It is this 15% that needs adjuvant chemotherapy (Paik, et al). There are several established biomarkers that are prognostically valuable in breast cancer. These include the presence of estrogen or progesterone receptors, HER2 amplification, as well as proliferative index, and histologic grade. Newer technologies such as gene expression such as the MammaPrint may also classify tumors to basal-like or luminal-type of disease. Since the OncotypeDX test returned intermediate results that did not allow a definitive decision on adjuvant treatment, the MammaPrint genetic test provided on 2/3/16 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: Upheld

Summary Reviewer 1
A 49-year-old female enrollee has requested reimbursement for endometrial ablation performed on 9/23/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that an endometrial ablation is a minimally invasive technique used to destroy the uterine lining for the treatment of chronic menorrhagia/abnormal uterine bleeding. This technique is supported by peer-reviewed current medical literature in patients who no longer desire fertility and in whom a thorough work-up has been performed to rule-out other causes of abnormal uterine bleeding. This evaluation includes performing a pelvic ultrasound and an endometrial biopsy/dilation and curettage (D&C). Furthermore, the patient should have tried and failed medical management options (such as birth control pills) over a reasonable period of time. Alternative treatment options, including hormones (pills, intrauterine device) and surgery, should be discussed. Based on review of this case, this patient had heavy menstrual cycles and cramping. The patient no longer desired fertility. She trialed a course of hormonal management with oral contraceptives. Per the available documentation, the patient has not responded to medical treatment and opted to undergo ablation. However, given the available clinical documentation, there is no evidence to support that the patient underwent a complete work-up to rule out other causes of abnormal uterine bleeding with endometrial sampling prior to the ablation. Therefore, endometrial ablation performed on 9/23/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 53-year-old female enrollee has requested reimbursement for gene testing performed on 11/15/16. 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 prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may also add a bit more to these prognostic statistics. As per these criteria, this patients melanoma would be classified as a stage 1A, with an expected ten-year survival of at least 88%. DecisionDx is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either Class 1 (with a 90-96% five year distant metastasis-free survival) or Class 2 (with a 65-80% rate). Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx classification, in patients undergoing sentinel node sampling, which was not documented in this case. Berger and colleagues reported on 156 cases, but there was not sufficient follow-up to determine the actual value of the assay. It is not clear how the five-year DecisionDx data compares to the ten-year Balch data, and whether it can be used to make clinical decisions. This would be particularly at issue in this patient given her excellent prognosis. All told, gene testing performed on 11/15/16 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 51-year-old female enrollee has requested reimbursement for chiropractic services provided on 5/19/16, 5/25/16, 6/02/16, 6/03/16, 6/06/16, 6/08/16, 6/10/16, 6/13/16, 6/20/16, 6/27/16, 7/01/16, 7/11/16, 7/18/16 and 7/21/16.  The Health Insurer has denied this request and reported that the services at issue were not medically necessary for treatment of the enrollees pain. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient has had extensive chiropractic treatment. The records noted that diagnosis of subluxation complex of vertebral of the head region, which is not what the patient states that she is being treated for or improving from. The providers notes are almost the same from each visit, and there is no documented functional improvement.  It is unclear how many visits were rendered under the diagnosis of subluxation complex of vertebral of the head region.  The current medical evidence does not support the services at issue in this clinical setting. All told, chiropractic services provided on 5/19/16, 5/25/16, 6/02/16, 6/03/16, 6/06/16, 6/08/16, 6/10/16, 6/13/16, 6/20/16, 6/27/16, 7/01/16, 7/11/16, 7/18/16 and 7/21/16 were not medically necessary for the treatment of this patient.  Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.