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

Summary Reviewer 3


A 53-year-old male enrollee has requested authorization and coverage for Inspire upper airway stimulation system.  The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees medical condition. The physician reviewer found the medical literature indicates that hypoglossal nerve stimulation for treatment of obstructive sleep apnea shows beneficial outcome with minimal adverse effect.   However, the superior effectiveness of the requested device has not been established.  Further independent outcomes data, including longer term results and effects of the device/procedure are needed before it is possible to state that hypoglossal nerve stimulation is likely to be more beneficial than standard therapies.  Thus, Inspire upper airway stimulation system is not likely to be of greater benefit than other treatment options.  Based upon the information set forth above, the requested device 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 24-year-old female enrollee has requested authorization and coverage for lymph node transfer procedure. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees lymphedema of the left lower extremity. The physician reviewer found that there is sufficient support in the medical literature for the requested procedure in this clinical setting. The patient has well documented evidence of continued lymphedema of the left lower extremity following a left inguinal node biopsy for treatment of angiomyomatous hamartoma. She is documented to have initiated control of her condition with commonly used modalities, including compression garments, pump, physical therapy and elevation. She has had two previous episodes of cellulitis with sepsis. Her examination documentation support that she has a condition of significant lymphedema that has not resolved but has progressed despite standard of care modalities.  Although her most recent documentation supports that she has improved lymphedema, she still has been documented to have complete obstruction of her deep lymphatics with shunting. Lymphedema treatment can be a difficult problem. The medical literature suggests that all attempts at standard of care management should be exhausted prior to any complex treatment.  Current standard of care management has failed in this patient.  Once lymphedema has begun, it can be difficult to treat and control nonoperatively. Thus, one must look to other forms of treatment when nonoperative measures have failed.  Over the years, there have been surgical techniques that have been developed for treatment. These options include lymph node transfer, some form of lympho-vascular anastomosis/bypass and lymphatic liposuction. There is support in the medical literature for the requested procedure. Given her significant history of cellulitis and sepsis, the procedure of lymph node transfer would benefit this patient.  There is enough evidence in the documentation provided as well as in the medical literature to support surgical intervention. In summary, standard available therapy has failed to resolve this patients lymphedema. She has already had severe infection associated with her lymphedema.  Therefore, lymph node transfer is medically necessary for treatment of this patients medical condition. Therefore, for the reasons stated above, the requested procedure is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 48-year-old male enrollee has requested reimbursement for Prometheus Anser IFX test performed on 8/24/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of ankylosing spondylitis and sacroilitis plus peripheral inflammatory arthritis. The physician reviewer found the medical research shows that anti-tumor necrosis factor agents have been associated to an increasing amount of auto-antibodies resulting in increased risk of infusion reactions, a reduced response to medications and the need for increasing dose adjustments. Up to about 50% of patients treated with infliximab develop these antibodies (Bendtzen, et al. (2006)). In a study by Baert and colleagues, they found that those patients with high antibodies had a higher risk of infusion reactions. In this patients case, he was having a recent flare of ankylosing spondylitis. It was unclear from the examination and supporting laboratory results if he was having a reaction to infliximab due to autoantibodies, which makes the infliximab ineffective and possibly harmful, or if he was no longer responding at his current dose, which would require an increase in medication.  The provider requested serologic testing to assess for antibodies against infliximab. The results of the test were negative and so, the patient was given an increased dose of infliximab and methotrexate. Therefore, for this patient, the testing proved helpful in identifying treatment options. As such, the Prometheus Anser IFX test was better than the standard method of evaluation which would have been to trial an increased dose of the medication and then monitor the patient for a reaction.  All told, the Prometheus Anser IFX test performed on 8/24/15 was superior to the available standard modality for the evaluation of this patients response to his current therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for the 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 41-year-old male enrollee has requested authorization and coverage for myoelectric, upper extremity orthosis. The Health Insurer has denied this request indicating that the requested equipment is considered investigational for treatment of the enrollee who had sustained an injury to his upper right arm. The physician reviewer found that the patient is a 41-year-old male who sustained a right brachial plexus injury due to a motorcycle accident in 2014. He underwent occupational therapy, which included electrical stimulation and static splinting. In July 2015 and February 2016, he underwent surgical intervention to include nerve and tendon transfers. He has regained antigravity strength in the right hand.  His right shoulder and elbow have poor minus strength.  The documents noted that the patient would like full independence and would like to return to work. The patient was an airline pilot. Myoelectric elbow wrist orthosis was prescribed to improve function requiring bimanual activities. The patient requested authorization and coverage for myoelectric, upper extremity orthosis. The Health Insurer denied the request noting that the requested equipment is experimental/investigational for treatment of this patient. The medical literature regarding the requested equipment is limited to preclinical work, developmental work and small anecdotal reports reporting its potential for benefit. The equipment is not yet proven to provide functional improvements over what can be achieved through standard occupational therapy interventions with static orthoses and durable medical equipment used for assisting with self-care and other activities.  Further studies are required to determine its efficacy as compared to standard means of treatment. In this patients case, there are no indications that the patient requires the equipment to perform his activities of daily living.  Current commercially available iterations of this type of equipment remain heavy, bulky, difficult to don, and difficult to use on a practical basis.  As such, the equipments safety and efficacy, in this clinical setting, have not been established. Therefore, the requested myoelectric, upper extremity orthosis is not likely to be more effective than standard equipment available for treatment of this patients medical condition.  Based upon the information set forth above, the requested equipment 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: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is a 64-year-old male who presented to the emergency department on 11/7/22 with 
a sudden onset of abdominal pain and vomiting. The patient has requested reimbursement for 
inpatient hospital stay at Tri City Hospital from 11/9/22 through 11/12/22. The Health Insurer 
has denied this request and reported that the services at issue were not medically necessary for 
the treatment of this patient. The physician reviewer found that the submitted documentation 
supports the medical necessity of the services at issue. In this case, the patient presented to the 
hospital with abdominal pain and vomiting. Imaging showed possible obstruction and colitis, and 
evaluation was recommended and found colonic inflammation and ulceration. The records noted 
that imaging showed further possible dilation of the colon two days after presentation. At that 
time, due to the possibility of worsening obstruction, colitis, or toxic megacolon, discharge would 
not have been appropriate. In this clinical setting, given the possible severity of the patients 
condition, the services at issue were medically indicated. Therefore, inpatient hospital stay at Tri 
City Hospital from 11/9/22 through 11/12/22 was medically necessary for the treatment of this 
patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 19-year-old female enrollee has requested reimbursement for the Anser IFX test provided on 2/16/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found that monitoring patients on infliximab with measurement of infliximab levels and antibodies to infliximab continues to be an area of intense investigation. In general, infliximab levels correlate inversely with disease activity. However there is a lack of controlled data which have identified the optimal drug level. Further, categorization of drug levels as high or low and antibody levels as high or low has not been validated using prospectively controlled data. All told, the Anser IFX test provided on 2/16/16 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 40-year-old female enrollee has requested reimbursement for CPT code 15847, excision, excessive skin and subcutaneous tissue provided on 1/25/16. The Health Insurer has denied this request indicating that the surgery at issue was not medically necessary for treatment of the enrollees hernia and diastasis recti. The physician reviewer found that the patient has a diagnosis of a reducible ventral hernia, excessive abdominal skin and a rectus diastasis. The pain is attributed to the rectus diastasis and ventral hernia, by evaluation of the provider who recommended a combined procedure. Conservative management stated by the patient included analgesics such as narcotics and over the counter medications. Overall, the patient has evidence of chronic back pain. However, it is not clear if the performed abdominal muscle plication was the likely source of her functional deficit of pain. The repair of diastasis recti is not generally considered to be a functional treatment but can be an integral part of cosmetic procedures including abdominoplasty. As stated by the American Society of Plastic Surgeons (ASPS), abdominoplasty and panniculectomy are typically performed for purely cosmetic indications. In evaluating functional status following abdominoplasty, Coriddi and colleagues noted that, rectus plication did not significantly improve functional outcomes. Oneal and colleagues state that non-operative therapy and significant work-up for other reasons of the pain should be evaluated prior to abdominoplasty with muscle plication. Given that the repair of diastasis recti is not well-recognized as a reconstructive procedure, repair of the diastasis recti was not medically necessary given the findings, review of the photographs, and documentation from the provider. The photographs show evidence of minimal skin excess and mild abdominal protuberance. The provider noted that on examination the diastasis is approximately 2-3 cm, which supports a mild condition. All told, CPT code 15847, excision, excessive skin and subcutaneous tissue provided on 1/25/16 was not medically necessary for treatment of this patients medical condition. Based on these findings, the surgery at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 48-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/12/17. 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 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 the DecisionDx-Melanoma testing for melanoma 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. Thus, DecisionDx-Melanoma testing performed on 12/12/17 was not likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 50-year-old male enrollee has requested reimbursement for Guardant360 testing performed on 8/31/18. 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 molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care for patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Integration of plasma next-generation sequencing testing into the routine management of stage IV non-small cell lung cancer demonstrates a marked increase of the detection of therapeutically targetable mutations and improved delivery of molecularly guided therapy. In sum, Guardant360 testing performed on 8/31/18 was likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 62-year-old male enrollee has requested authorization and coverage for insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator. 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 medical evidence supports the requested services in this clinical setting. This patient meets clinical criteria for consideration of surgical management of the obstructive sleep apnea symptoms. Drug-induced sleep endoscopy documented the location of obstruction with anterior-posterior, but no concentric, collapse at the tongue base. The patient has failed a prior trial of continuous positive airway pressure therapy. Per the medical evidence, upper airway stimulation is a safe and effective therapy for patients with obstructive sleep apnea. Woodson and colleagues noted long-term improvements and reported that adverse events were uncommon. In sum, insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator is likely to be superior over other treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 37-year-old female enrollee has requested reimbursement for gene testing provided on 9/16/15. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees breast cancer. The physician reviewer found that the patients with metastatic breast cancer encounter off-label therapies that may be supported by medical evidence. Von Hoff and colleagues studied 86 patients where the progression-free (PFS) survival on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has significant results for patients with stage IV tumors. This patient will be offered something off-label or a phase I/II clinical trial but with the results from molecular profiling offer a rational selection of the next regimen. In addition, more recent data on breast cancer also supports the use of Foundation One testing (Parker, et al). In sum, the gene testing provided on 9/16/15 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 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 3

A 37-year-old female enrollee has requested authorization and coverage for lymphaticovenous anastomosis and intraoperative indocyanine green lymphatic mapping. 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 Lymphovenous anastomosis is indicated for patients with early lymphedema who have failed nonoperative management. In order for lymphovenous anastomosis to be effective, the affected extremity must have partially functioning lymphatics and minimal fibrosis. Scaglioni and colleagues conducted a meta-study of lymphovenous anastomosis surgery. The authors noted, aA total of 293 titles were identified, out of which 18 studies including 939 patients were deemed eligible. The studies included in this review describe significant variations in surgical techniques, number of anastomoses and supplementary interventions. All studies reported objective reductions in circumference measurements. Subjective symptom relief was found in 50a100% of the patients as well as a reduction in the number of cellulitis episodes in all investigated cases.a A meta-analysis by Basta and colleagues found that excess circumference and limb volume were decreased by an average of 48.8% and 56.6%, respectively. They also report a 91.2% subjective improvement in symptoms. Quality of life has also been shown to be significantly improved. While randomized control trials that are needed to clarify indications and refine techniques for optimal patient care, lymphaticovenous anastomosis in particular, appears to be a technique that is finding wider use as a valuable tool in treatment of early stage lymphedema. Therefore, lymphaticovenous anastomosis and intraoperative indocyanine green lymphatic mapping is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

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 the patient has a 3.3 cm thyroid nodule, which had previously shown a biopsy consistent with FLUS. In FLUS the risk of malignancy if 5-15% (Cibas, et al). The most recent cytopathology was consistent with follicular neoplasm, which has a risk of malignancy of 15-30%. For FLUS, the Bethesda System recommends a repeat biopsy and for follicular neoplasm, a diagnostic lobectomy. 

The American Thyroid Associations guidelines state that for nodules with FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. In this case, the likelihood of the nodule being benign was high. With the negative result, the patient and provider can decide whether to continue surveillance versus diagnostic thyroidectomy. Given this support, the ThyGenX Thyroid Oncogene Panel testing provided on 11/18/15 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 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.