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

Summary Reviewer 2


A 20-year-old female enrollee has requested reimbursement for Anser IFX diagnostic test performed on 2/8/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees chronic ulcerative pancolitis. The physician reviewer found that the use of Anser IFX test to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with inflammatory bowel disease. The Prometheus Anser IFX test is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies. Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures. 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 infliximab or the presence of IFX antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there are few well controlled clinical trials to confirm that use of Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. As such, 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 the study does not compare these management changes to those made in the absence of anti-drug antibody measurement (Yanai, et al). Moreover, the medical literature 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. This appears to be the case with this patient, since available records do not support a clinical presentation that raised concern for loss of drug response or for the development of drug antibodies at the time of her test. For these reasons, the Anser IFX diagnostic test administered on 2/8/16 was not likely to have been superior to the other standard therapies available for the evaluation of this patient. Based upon the information set forth 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

A 39-year-old male enrollee has requested reimbursement for Anser IFX testing provided on 4/23/14. 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 submitted documentation fails to demonstrate the superior efficacy of the services at issue.  The medical evidence has not established whether therapy guided by following trough drug levels and drug antibodies is superior to routine good clinical care.  The data available are uncontrolled and come from retrospective analyses.  In general, for a patient failing therapy, there is a trend toward lower trough drug levels with or without the presence of antibody.  However, many patients fail therapy with a normal drug level for a variety of reasons.  All told, Anser IFX testing performed on 4/23/14 was not likely to have been more effective than other methods of evaluation.  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 55-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 5/29/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that this patient has an early stage melanoma. Commercially available gene expression profiling (GEP) tests are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear whether these tests provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariable nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. All told, DecisionDx-Melanoma testing provided on 5/29/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 39-year-old male enrollee has requested authorization and coverage for the LINX procedure.  The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found the appropriate patient selection is crucial before anti-reflux procedures. In prelude to surgical intervention for GERD, it is critical to document the presence of abnormal distal esophageal acid exposure, especially when anti-reflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and workup of GERD, and no single test alone can provide the entire clinical picture. Results of testing are combined to document the presence and extent of the disease and assist in planning the operative approach. Currently, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for anti-reflux surgery (Jobe, et al). In this case, the patient has undergone only some of this pre-operative assessment. Moreover, this patient presents with GERD with finding of short-segment Barretts esophagus and implantation of LINX has not been studied in patients with Barrett's esophagus (USC Keck School of Medicine). Therefore, the LINX procedure 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 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a 16-year-old female enrollee has requested reimbursement for mental health residential level of care provided from 7/17/19 through 9/17/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 3. The medical records indicate that the patient was not actively suicidal, but she did have a history of speaking of suicide and some mention of thoughts without plan during treatment. Further, there is history of a previous suicide attempt in the past.  With regards to functional status, the records support a score of 2. The patient demonstrated significant improvement in function following a period of deterioration. She had good grades in school prior to admission. In terms of comorbidity, the records support a score of 1. The patient did not have active medical problems or active substance use issues. With regards to level of stress of the recovery environment, the records support a score of 2. There was no indication of an unsafe home environment. In terms of level of support of the recovery environment, the records support a score of 2. The patients family was actively involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 3. It appears that the patient had not engaged in significant treatment prior to residential treatment admission. Per the records, her only treatment was weekly therapy, which did not appear adequate for her symptoms. It would not be expected that symptoms would resolve with this minimal outpatient treatment and no psychiatric management. In terms of acceptance and engagement of the patient, the records support a score of 2. The patient was cooperative in treatment. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 17. This score correlates with intensive outpatient services. Therefore, mental health residential level of care provided from 7/17/19 through 9/17/19 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 39-year-old female enrollee has requested reimbursement for Prometheus Anser ADA testing performed on 1/27/15. 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 testing at issue was not likely to be more effective for this patient than other available options. Prometheus Anser ADA is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions, as well as delayed hypersensitivity reactions. There are few well controlled clinical trials to confirm that use of the Prometheus Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. Generally, except on a rare case-by-case basis, diminished or suboptimal response to infliximab or adalimumab can be managed in several ways such as shortening the interval between doses, increasing the dose, switching to a different anti-tumor necrosis factor (TNF) agent (in patients who continue to have loss of response after receiving the increased dose), or switching to a non-anti-TNF agent based on clinical observation in lieu of Prometheus Anser ADA testing. In this case, the Anser testing was of questionable clinical significance. Moreover, the Prometheus Anser ADA results did not immediately alter the patients treatment course or result in a net positive clinical outcome. 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 2

The patient is a 58-year-old male with a left-sided clinical stage IV invasive breast cancer that is estrogen receptor (ER) positive, progesterone receptor (PR) positive, Her2 negative, and grade 3. He has a single bone metastasis in the right acetabulum. He was treated with neoadjuvant chemotherapy followed by mastectomy with sentinel lymph node biopsy. Pathology showed a good response to chemotherapy with negative margins. Repeat positron emission/computed tomography (PET/CT) showed uptake limited to the right acetabulum. The patient has requested authorization and coverage for stereotactic body radiotherapy (SBRT). The Health Insurer has denied this request indicating that the requested services are considered investigational. After review of available studies, the requested SBRT is likely to be more beneficial for the patients solitary bone metastasis secondary to breast cancer than conventional treatment consisting of conventionally fractionated radiotherapy. The current data demonstrates superior and more durable local control with SBRT for oligo-bone metastases with low toxicity. Chow and colleagues performed a systematic review of several different regimens of conventionally fractionated radiotherapy and demonstrated an overall response rate of approximately 60% with SBRT. Owen and colleagues reported on 74 patients with oligometastatic non-spine bony metastases of varying histologies that were treated with SBRT resulted in a one year local control rate of 91%. In this clinical scenario, it would be advantageous to provide a treatment for this patients bone metastasis with an expected response rate greater than 60%. Thus, the requested SBRT is 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 services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 49-year-old male enrollee has requested reimbursement for the platelet rich plasma injection performed on 1/4/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for treatment of the enrollees left foot pain. The physician reviewer found the platelet rich plasma injection performed on 1/4/17 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The documentation submitted for review indicates that the patient has failed splinting, oral anti-inflammatory medications, steroid injections, as well as orthotics. Length of time of each treatment, number of injections, and strength of injections is needed to assess whether patient has undergone proper conservative treatment. Furthermore, it does not appear the patient has undergone the standard of care treatments for posterior tibial tendon dysfunction including immobilization and casting. Furthermore, platelet rich plasma injections have demonstrated only mild efficacy for certain pathologies including plantar fasciitis, as well as tendon dysfunctions. Studies advise that further research is needed to fully understand the efficacy of platelet rich plasma, especially in joint pain and arthritis. For the reasons provided, the service at issue 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 service at issue was 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 1


The parent of a four-year-old male enrollee has requested reimbursement for comparative genomic hybridization performed on 1/19/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found Array-based comparative genomic hybridization has become standard of care to investigate children with developmental delay, intellectual disability, autism spectrum disorders or congenital anomalies. Until recently, it was a diagnostic test that was employed when the first-line investigation of karyotype returned normal.  Over the last eight years, it has emerged as a first-line investigation.  This test has become an important and mainstream tool in the practice of clinical genetics.  Data have now emerged showing that actionable findings from chromosomal microarray justify its use.  All told, comparative genomic hybridization performed on 1/19/15 was likely to have been superior over other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 50-year-old female enrollee has requested reimbursement for the injection of periurethral bulking agent provided on 12/19/14. The Health Insurer has denied this request indicating that the service at issue was considered investigational for treatment of the enrollees recurrent stress urinary incontinence and intrinsic urethral sphincter deficiency.   The physician reviewer found that endoscopic bulking is an accepted option specifically under this clinical scenario as noted in the American Urological Association (AUA) guidelines on incontinence. There is adequate data that endoscopic bulking is the least invasive among the available treatment options and most likely to improve this patients clinical concern of stress incontinence with intrinsic sphincter deficiency. All told, the injection of periurethral bulking agent provided on 12/19/14 was 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 service at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 22-year-old male enrollee has requested reimbursement for surgical treatment of femoroacetabular impingement syndrome performed on 12/23/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees hip pain. The physician reviewer found there is limited level 3 and 4 evidence in the current evidence-based medical literature in support of the addition of capsular plication for arthroscopic treatment of femoroacetabular impingement syndrome, with additional longer term outcome studies recommended. This patient with chronic function-limiting right hip pain. Clinical examination findings were consistent with imaging and radiographic evidence of a right hip labral tear and femoroacetabular impingement syndrome. There was no documentation of hip instability on clinical examination. He underwent right hip arthroscopic labral repair, acetabular rim trimming, femoral osteochondroplasty, and capsular plication on 12/23/15. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of capsular plication for the treatment of femoroacetabular impingement syndrome. Therefore, surgical treatment of femoroacetabular impingement syndrome performed on 12/23/15 was not likely to have been superior over other available treatment alternatives. 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a 17-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation device. The Health Insurer has denied this request and reported that the requested device is not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation supports the requested device in this clinical setting. This patient has a history of chronic migraine which evolved into chronic daily headache following three concussions. She has had inadequate symptom relief from both prophylactic and acute abortive medications, together with a variety of non-pharmacologic therapies. She has had an excellent response to transcranial magnetic stimulation, with a decrease in her headache frequency from daily headaches to two to four headaches per month. Irwin and colleagues conducted an open-label prospective pilot feasibility study of single-pulse transcranial magnetic stimulation (sTMS) for migraine prevention in adolescents aged 12-17 years. Participants used sTMS twice daily in a preventative fashion, as well as additional pulses as needed acutely. A four-week baseline run-in period (weeks 1-4) was followed by a 12-week treatment period. The authors concluded that sTMS appears to be a feasible, well-tolerated, and acceptable nonpharmacologic preventive treatment for migraine in adolescents. There is sufficient support for the requested device in this clinical setting. Therefore, the requested transcranial magnetic stimulation device is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 40-year-old female enrollee has requested reimbursement for fetal sex chromosome analysis, circulating cell-free fetal DMA in the maternal blood provided on 6/13/19. 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 this patient underwent prenatal testing on 6/13/19. She was pregnant at 11 weeks 2 days gestation at the time of services. This was her second pregnancy, and an earlier pregnancy ended in a spontaneous miscarriage. Noninvasive prenatal screening by cell-free DNA is increasingly becoming accepted as an appropriate method for first trimester aneuploidy screening. Noninvasive prenatal screening is a sensitive screen for aneuploidy. It is more sensitive than sequential screening, but does not require the invasive procedure of chorionic villus sampling or amniocentesis. This is the case for both younger women and for women of advanced maternal age. Offering diagnostic testing via chorionic villus sampling or amniocentesis is considered standard accepted practice in women over 35 years at the time of delivery, and noninvasive prenatal screening by cell-free DNA testing should also be considered standard. Therefore, fetal sex chromosome analysis (CPT 81599) performed on 6/13/19 was likely to have been more beneficial than other methods of evaluating this patient.