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

Summary Reviewer 2


A 57-year-old female enrollee has requested reimbursement for Afirma Thyroid FNA Analysis performed on 12/4/14. 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 in this case, the patient presented with a thyroid nodule with suspicious features. In this clinical setting the risk of malignancy may be as high as 70-90% (Haugen, et al). The cytopathology was consistent with atypia of undetermined significance (AUS), therefore, the specimen was sent to Afirma Thyroid FNA Analysis, which was consistent with a benign finding. The Bethesda System recommends a second fine needle aspiration (FNA) when the cytopathology is consistent with AUS. The 2015 American Thyroid Associations guidelines indicate that for nodules with AUS 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. FNA with molecular testing is considered standard of care in this clinical setting. Proceeding directly to the Afirma Thyroid FNA Analysis prevented a second biopsy and or diagnostic thyroidectomy with its possible complications. All told, the Afirma Thyroid FNA Analysis performed on 12/4/14 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, 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 3

A 57-year-old male enrollee has requested reimbursement for automated nerve conduction testing performed on 10/20/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found that the automated nerve conduction studies in dispute performed during surgery are not supported in the peer-reviewed literature. Intraoperative monitoring utilizing automated nerve conduction testing on peripheral nerves during surgery was not indicated. There is a lack of support in the medical literature supporting nerve conduction velocity monitoring on peripheral nerves during cervical spine surgery. As such, the automated intraoperative nerve conduction studies were 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 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  
The patient is  a  27-year-old male who was  admitted  for  hospitalization  on  8/13/21  after 
presenting  with  progressively  worsening  abdominal  pain  with  vomiting.  The  patient  has 
requested reimbursement for inpatient admission (hospital treatment services) from 8/13/21 
through 8/15/21. The physician reviewer found that at issue is whether inpatient admission 
(hospital treatment services) from 8/13/21 through 8/15/21 was medically necessary for the 
treatment of this patient. The submitted documentation does not support the medical necessity 
of the services at issue. Inpatient care may be necessary when a patients signs, symptoms, and 
general medical condition can only be managed safely in an acute inpatient setting, when a 
patient requires diagnostic studies in an inpatient setting, or when it is necessary for the patient 
to remain in an acute inpatient setting. In this case, the patient was hemodynamically stable and 
afebrile at admission. After treatment in the emergency department, the patients symptoms of 
pain and vomiting improved. The records did not indicate that the patient required any urgent 
procedures or surgical intervention. He did not have any significant electrolyte disturbances. He 
was treated with a nasogastric tube for a short time but able to tolerate oral nutrition shortly 
after  admission.  His  symptoms  improved  quickly  with  treatment  and  he  did  not  have 
complications. Given that this patient was in stable condition at admission and could have been 
treated at a lower level of care, the services at issue were not medically indicated. Therefore, 
inpatient  admission  (hospital  treatment  services)  from  8/13/21  through  8/15/21  was  not 
medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3 
 
A 50-year-old female enrollee has requested authorization and coverage for Balversa 4 mg 
tablets (two tablets per day). The Health Insurer has denied this request indicating that the 
requested medication is considered investigational for treatment of the insureds urothelial 
carcinoma. The physician reviewer found that molecular testing in patients with metastatic non-
small cell lung cancer has helped develop significant advances in therapy options for patients 
with improved patient health outcomes. Medical therapies such as Tagrisso are FDA approved 
for the treatment of patients with EGFR mutations. At this time, no FGFR inhibitor, such as 
Balversa, is approved for non-small cell lung cancer, but trials are ongoing. In addition, there is a 
lack of support from societal guidelines to include FGFR directed therapy in the management of 
non-small cell lung cancer. The patients recent improvement in CEA may be the result of Y90 
therapy, which was completed in 2022. The patients recent CT scan showed mixed response with 
some new growth in the lungs. Therefore, the requested Balversa 4 mg tablets (two tablets per 
day) is not likely to be more beneficial for treatment of the patients medical condition than any 
available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary  
The patient is a 53-year-old female with a history of unilateral primary osteoarthritis of the right 
hip  and  associated  severe  right  hip  pain.  The  provider  recommended  treatment  with  an 
arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), 
with or without autograft or allograft, and associated bed day. The physician reviewer found that 
at issue is whether the requested arthroplasty, acetabular and proximal femoral prosthetic 
replacement (total hip arthroplasty), with or without autograft or allograft, and associated bed 
day are medically necessary for the treatment of this patient. According to Rahm and colleagues, 
A total hip arthroplasty is indicated in end-stage hip osteoarthritis with a high degree of 
persistent suffering when conservative treatment has failed. In this case, the patient presents 
with a history of unilateral primary osteoarthritis of the right hip and associated right hip pain, 
stiffness, and tenderness. However, there is a lack of documentation of a formal diagnostic 
imaging  study to  corroborate  that the patients  hip  osteoarthritis is at relative end-stage. 
Therefore, the requested arthroplasty, acetabular and proximal femoral prosthetic replacement 
(total hip arthroplasty), with or without autograft or allograft, and associated bed day are not 
medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 59-year-old female enrollee has requested authorization and coverage for heart surgery to correct the heart valve using a catheter (transcatheter valve repair). 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 this patient has multiple comorbidities which make her high risk for open chest surgery, including prior extensive mantle irradiation with resulting scarring, restrictive lung disease, and a calcified porcelain aorta. There is ongoing published data supporting the safety and efficacy of transcatheter aortic valve replacement, especially in high risk or inoperable patients who require valve replacement. This patient fits into a very high risk category for open heart surgery, and this has been documented in her surgical consultations. Therefore, the requested services are likely to be of greater benefit than standard available therapy, which in this case is open heart surgery. Thus, the requested heart surgery to correct the heart valve using a catheter (transcatheter valve repair) is likely to be more effective than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 58-year-old female enrollee has requested reimbursement for the blood test (Guardant360 biopsy-free tumor sequencing test) performed on 12/8/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees stage lung adenocarcinoma. The physician reviewer found that Guardant360 testing offers a comprehensive panel of molecular genetic markers on an individual patients tumor in an attempt to identify markers than can help guide therapy decision making. Per the National Comprehensive Cancer Network (NCCN) guidelines, it has not been determined if molecular markers are useful in treatment determination other than EGFR, ALK, ROS-1, PDL1, MET, RET, ERBB2, and BRAF. There is currently a phase II clinical trial underway that is evaluating the efficacy of broad genetic molecular testing to guide individual therapy (Masters, et al). In this case, the metastases were noted to be difficult to biopsy, which supports the additional genetic testing with Guardant360 for EGFR, ALK, ROS-1, PDL1, MET, RET, ERBB2, and BRAF. For these reasons, the EGFR, ALK, ROS-1, PDL1, MET, RET, ERBB2, and BRAF portions of the blood test (Guardant360 biopsy-free tumor sequencing test) performed on 12/8/17 were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the remainder of the testing performed on 12/8/17 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, a portion of 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 partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is an eight-year-old male with a medical history of congenital torticollis, gastroesophageal reflux disease, and neurofibromatosis, type I. The patientas parent has requested reimbursement for inpatient level of care provided from 5/12/21 through 5/13/21. The Health Insurer has denied this request and reported that the services at issue were 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 services at issue. Acute appendicitis is one of the most common sources of acute abdominal pain in children, particularly for those between 4 and 15 years of age. While the classic presentation is that of periumbilical abdominal pain that localizes to the right lower quadrant, with anorexia and fever, there are many exceptions to this presentation. Fever may or may not be present, and pain may not yet be localized early in the course of appendicitis. Physical examination findings typically include signs and symptoms of peritonitis with localization to the right lower quadrant, but this is dependent on the intra-abdominal location of the appendix. While most patients have an elevated white blood cell count, a normal value does not rule out appendicitis. Diagnostic studies include abdominal ultrasound and abdominal computed tomography (CT) scan. The usual findings on CT include an enlarged, edematous appendix, with fat stranding in the right lower quadrant indicative of adjacent inflammation. In the absence of classical findings, with up to 50% of children presenting with an atypical history, the differential diagnosis is quite broad. Management of early acute appendicitis includes intravenous fluids, antibiotics, and pain medication. Appendectomy typically occurs within the first 12-24 hours after diagnosis. Perforation can occur, and results in a much more complicated course. The outpatient laparoscopic procedure is reserved for patients with uncomplicated appendicitis. In this patientas case, given the free fluid in the pelvis, it was not completely clear if this patient had a ruptured appendicitis or not. Second, there was evidence of peritoneal abscess upon laparoscopic investigation. Patients such as this must be monitored closely postoperatively because just as often as not, the abscess fluid re-accumulates and they require additional surgical procedures, or at the very least interventional radiology placement of pigtail catheters to drain. This patient had complicated appendicitis secondary to abscess formation as well as concern for rupture. Consistent with both care guidelines and the standard of care, acute inpatient admission was medically necessary and appropriate. Therefore, inpatient level of care provided from 5/12/21 through 5/13/21 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 49-year-old male enrollee has requested reimbursement for Oncotype DX Colon Cancer Assay performed on 5/29/14. 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 the current medical evidence has not demonstrated the superior efficacy of the services at issue.  Clinical validation has shown that recurrence scores are prognostic for survival, recurrence and disease-free survival, but are not predictive of response to adjuvant therapy.  Thus, there is a lack of support for the services at issue to predict response to chemotherapy.  At this time, the services at issue are not standard of care.  In sum, Oncotype DX Colon Cancer Assay performed on 5/29/14 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 61-year-old male enrollee has requested reimbursement for surgical services (atrial fibrillation ablation) performed on 7/10/13. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees recurrent symptomatic atrial fibrillation. The physician reviewer found the surgical services performed on 7/10/13 were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based on the documentation submitted for review, the patient presented with symptomatic paroxysmal atrial fibrillation in spite of a prior remote ablation in 2011 and suppressive antiarrhythmic medication trials. Since the patient continued to have significant symptoms in spite of attempts at rate control and rhythm control a second atrial fibrillation ablation procedure in this clinical setting was reasonable and medically appropriate and considered the standard of care in the medical community. The highest success in preventing atrial fibrillation with ablation is in those patients with paroxysmal (as opposed to persistent) atrial fibrillation (January, et al). Also, cryoablation has favorable results compared to radiofrequency ablation (Packer, et al). Given that the repeat ablation procedure performed on 7/10/13 was clinically indicated to relieve symptoms and is the standard of care in the medical community, the surgical services at issue were 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 services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 20-year-old male enrollee has requested reimbursement for the Anser IFX testing provided on 10/26/15. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease status post resection. The physician reviewer found that the patient has had Crohns disease that necessitated bowel resection. The records indicate the patients ileitis has also been complicated by Clostridium difficile and abscess. The patients symptoms remained active and it was unclear whether it would be Crohns disease from undertreatment or antibody development versus other complicating factors. Hence, an Anser IFX test was sent to help determine such. In this case, there is concern as the disease is advanced and the patient had already failed several regimen and flared on all. The concern between total loss of response, low antibody level to the biologic, or a completely different diagnosis such as inflammatory bowel disease entails different and drastic measures varying from surgery, change or increase in dose of biologic, to symptomatic adjunct treatment in case of inflammatory bowel disease. Therapeutic levels and lack of antibodies may point the provider toward a different drug versus another etiology. It follows, that testing for antibodies identifies the subset of patients who will benefit from an increased dose, instead of doing such blindly and risking unnecessary potentially risky outcomes and adverse effects. Conversely, missing a sub-therapeutic Remicade level suggests progression of the disease, which could be avoided by dose adjustment as guided by the Anser IFX assay. Moreover, it has been shown that checking for such antibodies helps optimize clinical response by helping achieve a more optimal drug concentration. For these reasons, the Anser IFX testing provided on 10/26/15 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: Upheld

Summary Reviewer 2


A 44-year-old female enrollee has requested reimbursement for Prometheus testing performed on 4/30/15.  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 the current medical evidence has not demonstrated the superior effectiveness of the services at issue.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of adalimumab or the presence of adalimumab antibodies may have an adverse effect on the clinical outcome of a patients response to treatment.  However, while there have been testimonials, there are few well-controlled clinical trials to confirm that the testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  In sum, the services at issue were not likely to have been of greater benefit than other methods of evaluating this patient.  In sum, the services at issue were 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 1

The patient is a 41-year-old male with chronic migraine. On 10/16/17, Botox injections were provided. He reported 15 headaches per month lasting more than four hours associated with migraine symptoms at the start of treatment. The patient has requested reimbursement for Botox injections provided on 10/16/17 and 1/08/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of this patient.  The use of Botox is indicated for the treatment of chronic headaches in individuals who have at least 14 headache days per month. This patient reports that he experiences 15 headache days per month. Furthermore, Botox has been approved by the U.S. Food and Drug Administration for the treatment of migraines. Therefore, Botox injections provided on 10/16/17 and 1/08/18 were likely to be more effective than other treatment options. Based upon the information set forth above, the services at issue were 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 52-year-old female with a reported history of chronic back pain dating back to 2005.The patient has requested authorization and coverage for cervical spine MRI and thoracic spine MRI. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient. The physician reviewer found that there are two studies currently under question. The first is an MRI of the cervical spine. In the medical records, there is no mention of any signs or symptoms pointing to the neck. In view of this, there is no indication for any imaging of the cervical spine. For the thoracic spine MRI, the records noted that the patient had a T3-4 radiculopathy. Conceivably, she could have a compression fracture or focal arthritic change. Remotely, she could even have a significant lesion, such as a severe fracture or even a mass. While the likelihood of these possibilities is low, an MRI is the best means to pick up a focal abnormality. The presence of radiculopathy is also considered a legitimate indication for an MRI. In conclusion, there is no indication for a cervical spine MRI. However, the thoracic spine MRI could help in management, Therefore, the requested thoracic spine MRI is medically necessary for the evaluation of this patient.