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

Summary Reviewer  A  55-year-old female enrollee has requested reimbursement for DecisionDX-melanoma laboratory testing performed on 5/13/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found that the staging and prognosis of cutaneous malignant melanoma is classically determined by the system spelled out by Balch and colleagues. There may be some further value in adding the mitotic rate to this system.  As per this system, this patient was staged as T1a, melanoma, with no mitoses seen. This would have an expected ten year survival of at least 88%.  There is no information in the records submitted as to whether she had sentinel node performed. DecisionDX, melanoma assay is a study of 31 genes in melanoma cells.  It then classifies that particular melanoma as either class 1 (with a 97% disease-free rate at five years) or class 2 (with a 31% disease free-rate at five years).  It is not clear how DecisionDX data compares to the ten year data of the Balch determinations, and whether it can be used to make clinical practice decisions.  This is particularly in question in this patients case given her pathologic findings and excellent prognosis.  All told, DecisionDX-melanoma laboratory testing performed on 5/13/16 was not likely to have been more effective than other modalities for evaluating this patient. Therefore, for the reasons stated above, the services at issue were not likely to have been 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 1


The parent of a 13-year-old female enrollee has requested reimbursement for homocysteine testing performed on 12/31/15. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees behavioral health condition. The physician reviewer found the testing at issue was not likely to be more beneficial than any standard therapy available. There has been some research in non-traditional treatment of ADHD utilizing standard randomized double-blinded studies; however, research studies that have correlated the role of homocysteine levels to the diagnosis and treatment of ADHD or treatment of anger issues are lacking. A study by Kim and Lee looked at whether homocysteine has been associated with cognitive impairment and various psychiatric symptoms; however, the authors, did not discuss homocysteine testing and its benefit in managing either ADHD or anger. All told, the homocysteine test was not likely to be more beneficial for evaluating the patients ADHD or anger issues than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 44-year-old female enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan of parathyroid gland provided on 7/19/16. The Health Plan has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees hyperparathyroidism.The physician reviewer found the SPECT scan of parathyroid gland provided on 7/19/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is also ample literature to support its use in the surgical localization of parathyroid disease. The SPECT scan helps locate the anatomical abnormality and can enhance surgical precision, leading to better clinical outcomes for the patient, as well as help to shorten operative times. In conclusion, the diagnostic procedure at issue 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 diagnostic procedure 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 2

A 60-year-old female enrollee has requested reimbursement for collagen crosslinks laboratory tests performed on 1/2/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees osteoporosis. The physician reviewer found that biochemical markers of bone remodeling or serum or urinary collagen crosslinks tests are useful in certain situations to monitor efficacy and compliance with therapies for osteoporosis. However, this is not yet standard of care in the medical community, though they have a role in certain clinical situations. In this patients case, the submitted records do not indicate that these tests at issue were superior to available standard therapies for evaluation and treatment of the patients osteoporosis. 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 


The patient is a 65-year-old male who underwent laboratory testing on 8/11/20.  The patient has requested reimbursement for magnetic resonance elastography performed on 10/07/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. This denial is the subject of the appeal and determination. The physician reviewer found that this patient has had elevated liver enzymes and imaging showing hepatomegaly with fatty infiltration, consistent with liver diseases including non-alcoholic fatty liver disease, non-alcoholic steatohepatitis, and autoimmune hepatitis. The American Association for the Study of Liver Disease (AASLD) guidelines for non-alcoholic fatty liver disease recommend assessment for liver disease, including fibrosis and cirrhosis. Magnetic resonance elastography is one method for the assessment of liver disease; it has a higher technical success rate than ultrasound elastography, superior accuracy to serum liver function testing for the detection of significant liver fibrosis, and the ability to reliably differentiate between early and late stages of hepatic fibrosis. American Gastroenterological Association (AGA) Institute guidelines for the role of elastography in chronic liver disease state that magnetic resonance elastography has considerably higher diagnostic accuracy in ruling out cirrhosis in patients who do not have cirrhosis than ultrasound elastography, and AGA Institute guidelines for the role of elastography in the evaluation of liver fibrosis recommend using magnetic resonance elastography rather than ultrasound elastography for detection of cirrhosis in patients with a risk for non-alcoholic fatty liver disease and a higher risk of cirrhosis. Given that liver disease (including non-alcoholic fatty liver disease) was suspected in this patient with elevated liver enzymes and hepatic steatosis on imaging, and guidelines recommend assessment for liver disease in such cases with modalities including magnetic resonance elastography, magnetic resonance elastography was medically indicated for the evaluation of this patients elevated liver enzymes and hepatic steatosis. Therefore, magnetic resonance elastography performed on 10/07/20 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The parent of a 15-year-old female enrollee has requested reimbursement for Prometheus Anser ADA testing performed on 10/10/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that measurement of adalimumab trough levels and antibodies is not investigational in the setting of inadequate response or loss of response to medical treatment. This approach is supported by the medical literature. However, in this case, the records indicate that testing was performed in October 2017, as a follow-up to dose intensification. At that point, the patient was feeling better and did not have clinical signs or symptoms to indicate non-response to her higher adalimumab dosing. The medical evidence does not support the services at issue in this clinical setting. Therefore, Prometheus Anser ADA testing performed on 10/10/17 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: Experimental
Decision: Upheld

Summary Reviewer 2


A 60-year-old male enrollee has requested reimbursement for St. Jude Nanostim Leadless Pacemaker implant provided on 6/24/15. The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found in this case, implantation of a permanent pacemaker was indicated given the patients history of syncope as well as documentation of a four second period of asystole. The implanting provider opined that given the patients active lifestyle he would be better served by a device that did not involve the implantation of transvenous leads. However, the St. Jude Nanostim Leadless Pacemaker is not U.S. Food and Drug Administration (FDA) approved. In addition, the current literature does not support a definitive long term benefit to health outcomes with the St. Jude Nanostim Leadless Pacemaker, and the long term safety and efficacy have not as yet been proven. All told, the St. Jude Nanostim Leadless Pacemaker implant provided on 6/24/15 was 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 services at issue were 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 50-year-old female enrollee has requested reimbursement for Afirma gene testing performed on 7/22/14. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that The American Thyroid Association (ATA) guidelines state For nodules with [atypia of undetermined significance/follicular lesion of undetermined significance] AUS/FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat [fine needle aspiration] 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 patient had a cytopathology result consistent with atypia of undetermined significance (AUS). Without this test, the patient would have required a second biopsy or surgery to clarify the diagnosis. Therefore the submission of the specimen to Afirma gene expression classifier was appropriate. The result was noted as suspicious which indicated a risk of malignancy of 40% in that nodule (Alexander, et al). The increased risk of malignancy justifies the decision to perform a thyroidectomy. With the size of the nodule the extension of the surgery can also be determined from the result. A benign result would have prevented an unnecessary surgery and its potential comorbidities. All told, the Afirma gene testing performed on 7/22/14 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 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 58-year-old female enrollee has requested reimbursement and prospective authorization and coverage for physical therapy services provided from 1/22/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees thoracic degenerative disc disease and facet dysfunction, lumbar foraminal and central stenosis. The physician reviewer found that although a multidisciplinary approach to spine pain including physical therapy may be beneficial, the goal of therapy is to transition to an independent home exercise program without continued dependence on supervised therapy. Based on the available records, the additional requested physical therapy is not supported as a specific and effective treatment for this patients medical condition. The documentation does not indicate that prior extensive physical therapy has resulted in significant objective increase in overall function. Moreover, the services provided from 1/22/16 forward do not need to be only under the supervision of a therapist. The patient has had extensive prior physical therapy and should be well versed in a home exercise program. The patients expected rehabilitation potential is not significant in relation to the extent and duration of the physical therapy services. The specialized skill of a qualified therapist is not required to establish, design and/or deliver a maintenance program to maintain the patients current condition or to prevent or slow further deterioration. All told, the physical therapy services provided from 1/22/16 forward were not and are not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 26-year-old male enrollee has requested reimbursement for inpatient hospital services provided from 4/12/18 through 4/17/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that in this case, the patient did not have high-risk features of a headache, including altered mental status, new neurologic deficit or associated seizures. He did not complain of a sudden-onset headache, and he had already been evaluated with multiple computed tomography (CT) scans of the head.  The inpatient admission was not medically necessary. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. Therefore, inpatient hospital services provided from 4/12/18 through 4/17/18 were not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 58-year-old female enrollee has requested reimbursement for autonomic nerve testing performed on 9/03/15. 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 that there is a lack of support for the services at issue in this clinical setting.  Limb pain is a symptom, not a diagnosis.  In this case, the medical records do not detail history or examination features that would suggest autonomic dysfunction.  Details of electrodiagnostic tests are not available for review.  Autonomic nerve testing has been determined to be useful in evaluation of syncope and of small fiber neuropathy.  The medical literature in these circumstances is mixed at best, with a lack of high quality, randomized studies.  In this patients case, there is not documentation in the submitted records which suggest need for autonomic testing.  All told, autonomic nerve testing performed on 9/03/15 was not likely to have been superior over 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: Upheld

Summary Reviewer 2

A 50-year-old female enrollee has requested authorization and coverage for minimally invasive sacroiliac joint fusion. 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 the submitted documentation fails to demonstrate the superior effectiveness of the requested services. While there is more convincing evidence to support arthrodesis for primary sacroiliac conditions with identified on imaging or with rheumatologic pathology such as trauma, tumor, spondyloarthropathy or infection, the evidence is much less clear when there is confounding degenerative pathology in the lumbar spine. In addition, the criteria for diagnosis of sacroiliac joint mediated pain remains unclear, and pain relief with injection is not recognized universally as the gold standard. In this case, the patient has been diagnosed with left sacroiliac joint dysfunction. She does have some physical examination findings that localize her symptoms to the left sacroiliac joint. However, there are no objective imaging or laboratory findings to indicate the presence of sacroiliac joint infection, tumor, sacroiliitis due to spondyloarthropathy or post-traumatic arthritis. The imaging studies do not demonstrate objective evidence of left-sided sacroiliac joint pathology but do demonstrate confounding multilevel lumbar degenerative changes. There is a lack of support for the requested services in this clinical setting. Therefore, the requested minimally invasive sacroiliac joint fusion is not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 1


A 63-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 6/11/15. 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 the review of the submitted documentation and relevant literature supports the services at issue in this clinical setting. While there is a lack of long-term studies proving increased survival rates when tomosynthesis is used as a mammographic tool the addition of the technique to both screening and diagnostic mammography has gained worldwide popularity among providers due to the advantage the technique offers by eliminating overlapping dense glandular tissue from being confused with mass or architectural distortion which in turn could indicate neoplasm. The addition of the technique has reduced callbacks and increased detection of small cancers. Thus, the use of tomosynthesis in this case helped eliminate the concern of underlying malignancy. Therefore, the digital breast tomosynthesis performed on 6/11/15 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 3

A 50-year-old female enrollee has requested reimbursement for breast tomosynthesis imaging performed on 2/10/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee who presented for her annual breast examination. The physician reviewer found that Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as CT scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. In recent years, there have been several studies that have supported the use of breast tomosynthesis as a more accurate study than routine screening mammography.  As Skaane concludes, in a study including 12,631 examinations, 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.   In this particular patient, she has breasts that have been described as extremely dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures better enables the possibility of demonstrating an otherwise occult tumor. In sum, breast tomosynthesis imaging performed on 2/10/17 was likely to have been more effective than the other methods for the evaluation of this patients medical condition. Based upon the information set forth above, the service at issue was 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.