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

Summary Reviewer 

The patient is a 58-year-old male with psoriasis. He has requested authorization and coverage for Otezla 30 mg. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that based on the psoriasis treatment guidelines put forth by the American Academy of Dermatology- National Psoriasis Foundation, patients who have psoriasis affecting between 3 to 10% (defined as moderate) and greater than 10% (defined as severe) of their body surface area are candidates for phototherapy and systemic medical therapy. There are no step therapy guidelines recommended in this context, and the choice of therapy should be made at the discretion of the treating provider, with attention paid to patient comorbidities. Otezla is U.S. Food and Drug Administration (FDA) approved and indicated for treatment of moderate-to-severe psoriasis and has Level A evidence to support its efficacy. Given that the patient has documented evidence of moderate-to-severe disease combined with the fact that there is documented evidence of effectiveness with starter pack samples, it is medically appropriate to continue this therapy. Therefore, Otezla 30 mg is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 54-year-old female enrollee has requested authorization and coverage for surgery to treat her heart rhythm. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee, who has a history of paroxysmal (AF) atrial fibrillation. The physician reviewer found that based on the records provided, this patient had atrial fibrillation that converted to normal sinus rhythm after treatment with Multaq followed by repeat cardioversion. There is a lack of documented recurrent atrial fibrillation since that time based on the records provided. Based on the records, atrial fibrillation ablation is not likely to benefit this patient. The patients symptoms persist but her nonspecific symptoms (malaise, fatigue) may not be due to atrial fibrillation. Current guidelines recommend consideration of atrial fibrillation ablation only if the patient has intolerance or recurrent atrial fibrillation in spite of at least one antiarrhythmic medication trial. In this patients case, the requested surgery to treat her heart rhythm is not likely to be more effective than the available standard therapy. Therefore, for the reasons stated above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
A 57-year-old male insured has requested reimbursement for a gene test (CPT 0047U) provided on 
3/10/22. The Health Insurer has denied this request indicating that the services at issue were considered 
investigational for the evaluation of the insureds prostate cancer. The physician reviewer found that Per 
the available records, this patient presented with a history of Gleason 3+3=6 prostate cancer with a PSA 
of 7.74 ng/mL. The patient underwent evaluation with Oncotype DX genomic prostate score testing. 
Once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by analyzing 
the grade of tumor and PSA level. Current studies in the peer-reviewed medical literature have 
demonstrated that the Oncotype DX Prostate Cancer Assay is beneficial as an addition to standardized 
testing in the assessment and treatment planning of patients with prostate cancer (Klein, et al.). The 
Oncotype DX is a gene expression analysis of target genes in the biopsy specimen that generates a 
genomic prostate score. The Oncotype DX can help guide the most appropriate therapy for patients, as 
well as determine which patients will not require treatment with surgery or radiation (Van Den Eeden, 
et al.). Overall, the use of prognostic biomarker testing with Oncotype DX has been shown to improve 
patient health outcomes (Klein, et al.). Furthermore, NCCN guidelines also support the use of Oncotype 
DX to better stratify patients with localized disease (Cullen, et al.). Therefore, the gene test (CPT 0047U) 
provided on 3/10/22 was likely to have been more beneficial for the evaluation of the patients medical 
condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3 
 
A 35-year-old female enrollee has requested reimbursement for colorectal cancer screening 
using chromoendoscopy or narrowband imaging optical colonoscopy performed on 1/25/22. The 
Health Insurer has denied this request and reported that the services at issue were investigational 
for the evaluation of the enrollees medical condition. The physician reviewer found that the 
current medical evidence supports the services at issue in this patients case. Most society 
guidelines  advocate  for  high-definition  endoscopy  with  surface  chromoendoscopy  or 
narrowband  imaging  as  the  strategy  that  optimizes  dysplasia  detection  in  patients  with 
inflammatory  bowel  disease,  including  ulcerative  colitis.  The  American  Society  for 
Gastrointestinal  Endoscopy  noted,  Recent  studies  utilizing  image-enhanced  endoscopy 
in inflammatory bowel disease (IBD) surveillance have led to new recommendations by several 
societies for optimal identification and management of IBD-related dysplasia. It is now believed 
that  most  neoplasia  is  endoscopically  visible  with high-definition  and/or  image-enhanced 
endoscopy (eg, chromoendoscopy). Most dysplasia previously detected during standard white-
light endoscopy (WLE) by random biopsy only and deemed invisible is, in fact, visible by enhanced 
imaging.  Therefore,  colorectal  cancer  screening  using  chromoendoscopy  or  narrowband 
imaging optical colonoscopy performed on 1/25/22 was likely to have been more beneficial than 
any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1 
 
A 56-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 6/04/21. The Health Insurer has denied this request and reported that the services at 
issue  were  investigational  for  the  evaluation  of  the  enrollees  medical  condition. 
The physician reviewer found that the use of gene expression profiling (GEP) testing according to 
specific  American  Joint  Committee  on  Cancer  (AJCC)  melanoma  stage  requires  further 
prospective investigation in large, contemporary datasets of unselected patients. Prognostic GEP 
testing to differentiate melanomas at low versus high risk for metastasis should not replace 
pathologic staging procedures. Moreover, since there is a low probability of metastasis in stage I 
(T1) melanoma and a higher proportion of false-positive results, GEP testing should not guide 
clinical decision-making in this subgroup. Therefore, DecisionDx-Melanoma testing performed 
on 6/04/21 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 65-year-old female enrollee has requested reimbursement for Cx Bladder testing performed on 7/02/18. 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 is insufficient support for the services at issue in this clinical setting. Establishment of bladder cancer diagnosis and the evaluation of microscopic hematuria for asymptomatic patients include imaging, cystoscopy and cytology. This patient was evaluated for microscopic hematuria with negative cystoscopy. Therefore, further testing with urine biomarkers was not indicated. At this time, the superior efficacy of the services at issue has not been established. Thus, Cxbladder testing performed on 7/02/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 63-year-old female enrollee has requested reimbursement for digital breast tomosynthesis provided on 1/21/16.  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 there is sufficient support for the services at issue in this patients case.  According to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  In sum, digital breast tomosynthesis performed on 1/21/16 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.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is a 54-year-old male. In a letter dated 2/18/22, the provider reported that the patient 
presented with neck, thoracic, and radiating arm pain. The patient has requested reimbursement 
for cervical spine MRI provided on 2/21/22. The physician reviewer found that the patient is a 
54-year-old male. In a letter dated 2/18/22, the provider reported that the patient presented 
with neck, thoracic, and radiating arm pain. The patient reported that his symptoms had started 
on Sunday morning, necessitating a visit to the emergency room by Monday night. He reported 
similar symptoms a year back, which had been treated with acupuncture. The records noted that 
computed tomography (CT) of the cervical spine dated 2/14/22 demonstrated diffuse spondylitis 
changes. The provider recommended magnetic resonance imaging (MRI) to evaluate for the 
possibility of disc disease. An MRI dated 2/21/22 showed severe disc protrusions at both C5-C6 
and C6-C7 where it narrowed the central canal to 0.2 cm, with severe stenosis. The patient has 
requested reimbursement for cervical spine MRI provided on 2/21/22. The Health Insurer has 
denied this request and reported that the service at issue was not medically necessary for the 
evaluation of this patient. This denial is the subject of this appeal and determination.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


An 18-year-old male enrollee has requested reimbursement for residential treatment services from 1/20/12 through 12/3/12. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found THE residential treatment services provided from 1/20/12 through 12/3/12 were not medically necessary for treatment of the patients medical condition. The patient does not meet the medical necessity criteria for residential level of care. Despite, being treated at the residential level of care for almost a year, there was a lack of treatment notes to assess the care provided. The records fail to contain a detailed mental status exam performed on 1/20/12 at UCLA, on the day prior to admission to treatment.  At that time, the patient did not have any major concerns noted. He was given a diagnosis of polysubstance abuse and depressive disorder NOS. According to the discharge summary, the reason for referral for further treatment was because the patient showed little insight into his substance abuse. The patient had no problems with his activities of daily living. He was not homicidal or suicidal and was noted to be cooperative. The UCLA records also indicate that the patient had not received any type of substance abuse treatment. In this clinical setting, the patient could have been safely and effectively managed at a lower level of care. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 63-year-old female enrollee has requested reimbursement for breast magnetic resonance imaging (MRI) performed on 3/14/16.   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 supports the services at issue in this clinical setting.  According to Warner and colleagues, screening with both MRI and mammography might rule out cancerous lesions better than mammography alone in women who are known or likely to have an inherited predisposition to breast cancer.  The literature supports the use of breast MRI for women with higher risk of breast cancer.  This patient has a strong family history of breast cancer, and it was appropriate to screen for breast cancer with MRI.  Thus, MRI of the breasts performed on 3/14/16 was likely to have been more effective than other modalities.  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 2

A 42-year-old male enrollee has requested authorization and coverage for an implanted neurostimulator pulse generator system. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees obstructive sleep apnea (OSA). The physician reviewer found that as noted in the medical literature, OSA is an increasingly prevalent clinical problem with significant effects. CPAP has demonstrated excellent efficacy and low morbidity with long-term adherence rates approaching 50%. Upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. Woodson and colleagues reported that the STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. This trial demonstrated the hypoglossal nerve stimulator to be safe and effective in a small subset of patients with OSA who have failed CPAP, with an AHI median value of 28.2 event per hour, a BMI less than 32, and nonconcentric airway collapse. However with an AHI of 61.1, this patient does not meet the criteria. For these reasons, the requested implanted neurostimulator pulse generator system 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 procedure 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 3

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 Based on current guidelines, lung adenocarcinoma should be evaluated for certain molecular abnormalities and mutations that have clinical implications. When this patient developed metastases, the FoundationOne assay was performed which did not reveal any significant mutations. In this case, the FoundationOne assay had already been performed, and this did not indicate any molecular or mutational results that could guide the provider. There is a lack of support additional testing with Guardant360 would have provided additional clinical benefit in this situation. Thus, the blood test (Guardant360 biopsy-free tumor sequencing test) 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, 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: Upheld

Summary Reviewer 2

A 38-year-old female has requested reimbursement for fecal calprotectin testing performed on 11/22/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative pan-colitis. The physician reviewer found that persistent disease activity is associated with a poor prognosis in inflammatory bowel disease. Therefore, monitoring of patients with intent to suppress subclinical inflammation has emerged as a reasonable community-standard treatment goal. As endoscopic monitoring is invasive and resource intensive, identification of valid markers of disease activity has been a priority. Calprotectin, when measured in feces, is commonly used in clinical practice to differentiate between non-organic and inflammatory intestinal disorders, especially to identify inflammatory bowel disease. Fecal calprotectin may also be useful to monitor patients with inflammatory bowel disease under treatment and to predict the risk of recurrence of active disease prior to clinical relapse. However, in this patients case, all available data at the time of the disputed service supported disease quiescence off conventional medications, as well as an absence of signs and symptoms attributable to inflammatory bowel disease. The medical evidence does not support the services at issue in this clinical setting. Therefore, fecal calprotectin testing performed on 11/22/17 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 54-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy less than 12 months due to non-liver-related conditions.  The guidelines support Harvoni for treatment-naive patients with hepatitis C, genotype 1 infection.  It is advantageous to treat patients before they progress to cirrhosis.  Based on evidence of safety and efficacy in the published literature, the requested medication Harvoni is medically indicated for the treatment of this patient.  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

A 37-year-old female has requested authorization and coverage for Gammagard liquid 10% vial. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollee, who has a history of recurrent pregnancy loss.  The physician reviewer found that although this therapy has been studied extensively for this purpose, it is not considered effective or appropriate outside of experimental protocols.  Branch and colleagues noted IVIG is no more effective than heparin and low-dose aspirin in the treatment of pregnancies complicated by antiphospholipid syndrome but has not been adequately evaluated in refractory cases. Finally, pending convincing studies, IVIG is not effective and should not be used for the management of recurrent miscarriage.  Either low-dose aspirin or heparin therapy is appropriate in this clinical setting. Ata and colleagues evaluated six randomized controlled trials including 272 women. They determined a beneficial effect of IVIG in treatment of recurrent miscarriage was not observed. Given the absence of a proven mechanism of action, and the lack of a diagnostic algorithm to identify patients who are likely to benefit from such treatment, IVIG administration for treatment of recurrent miscarriage is not justified outside the context of properly designed randomized clinical trials. Therefore, Gammagard liquid 10% vial is not likely to be more efficacious than other available treatment options. Based upon the information set forth above, the requested medication 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 47-year-old female enrollee has requested authorization and coverage for a sleep study.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees medical condition.  The physician reviewer found there is sufficient support for the requested services in this patients case.  Diagnostic sleep studies are indicated for patients with an increased risk of obstructive sleep apnea. In this patients case, she has a very high risk of obstructive sleep apnea because of obesity, witnessed apnea and elevated Epworth Sleepiness Scale score.  The records document awakening gasping and snoring.  Since she has a high risk of sleep apnea, the requested sleep study is appropriate.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested sleep study is medically indicated for the treatment of this patient.  Therefore, the requested services are medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.