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

Summary Reviewer 



A 54-year-old male enrollee has requested authorization and coverage for apremilast (Otezla) 30 mg tablets. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriatic arthritis. The physician reviewer found that the documentation provided do not support the medical necessity for the requested medication in this clinical setting. While the records indicate that this patient has failed two treatments with NSAIDs, the records do not demonstrate that he has tried and failed nonpharmacological treatments (ultravioletlight therapy), disease-modifying antirheumatic drugs (DMARD) therapies, or anti-tumor necrosis factor (TNF) agents. There is also no documentation that he has tried the standard topical therapy to address the psoriasis that covers at least ten percent of his body surface area. While apremilast may represent a promising therapy for the treatment of psoriatic arthritis and psoriasis, the medication should be tried after failure of other standard forms of therapy. Per Zerilli, and Ocheretyaner, Additional long-term studies are needed to further elucidate its place in therapy. As such, the requested medication is not medically indicated for the treatment of this patient. Therefore, for the reasons stated above, the requested medication is 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 27-year-old female enrollee has requested reimbursement for genetic testing including methylenetetrahydrofolate reductase (MTHFR) gene analysis, common variants, and factor V Leiden mutation testing provided on 7/1/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for bleeding disorder.  
 
 The physician reviewer found that the Pulmonary embolism (PE) and DVT may be caused by hereditary thrombophilias. The increased risk is worth knowing especially in situations of pregnancy, estrogen therapy, and prolonged immobility, such as surgery, long car trips, or long airplane flights. These complications may be prevented by appropriate interventions. There is strong medical evidence supporting factor V Leiden testing. There is a known interaction between estrogens and the mutation. Importantly, research indicates that the prothrombin G20210A mutation adds to this risk such that compound heterozygous patients can have up to 20 fold increased odds of developing DVT (Emmerich, et al).  Accordingly, this patients case genetic testing including MTHFR gene analysis, common variants, and factor V Leiden mutation testing provided on 7/1/17 was likely to have been of greater benefit than the standard methods of evaluating this patients medical condition. 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 57-year-old female enrollee has requested reimbursement for the gene test performed on 8/12/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that there is a lack of medical studies to support the superior efficacy of this gene test in this patients case. The standard therapy for stage I malignant melanoma is surgical excision. The current body of medical research indicates that there is very little benefit from adjuvant therapy. The clinical trials have only looked at adjuvant therapy in lymph nodes positive for the disease. Regardless of the risk or recurrence determined by this test, the implications on therapeutic decisions cannot be validated by data and therefore, would not help direct therapy. Moreover, the gene test has not been shown to improve a patients health outcome over established alternatives. For these reasons, the gene test performed on 8/12/15 was not likely to have been more effective than available standard tests for the evaluation of 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 56-year-old female enrollee has requested reimbursement and prospective authorization and coverage for Optune electrical stimulation device from 4/20/15 forward. The Health Insurer has denied this request indicating that the device at issue was not and is not medically necessary for treatment of the enrollees recurrent glioblastoma multiforme. The physician reviewer found The central nervous system tumors are classified by the World Health Organization (WHO) based on their proliferative potential, morphology, and molecular genetics and are conferred grades I-IV.  Anaplastic astrocytomas and glioblastoma multiforme are high grade tumors that are best treated with resection, radiation therapy, and chemotherapy. This patient has exhausted all these options.  In 2011, the U.S. Food and Drug Administration approved the NovoTTF-100A device, now known as the Optune electrical stimulation device, to deliver alternating electrical fields to treat recurrent glioblastoma multiforme.  The approval was based on a randomized clinical study where 237 patients were treated with either NovoTTF versus best standard of care chemotherapy, including bevacizumab.  There was no difference in overall survival between the two arms.  The Optune electrical stimulation device is medically indicated for this patient who has exhausted standard treatment options.  There is sufficient medical evidence to demonstrate the safety of this device.  All told, Optune electrical stimulation device from 4/20/15 forward was and is medically indicated for the treatment of this patient.  Therefore, the device at issue was and is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 62-year-old female enrollee has requested reimbursement for FoundationOne CDx test performed on 12/31/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeAaas medical condition. The physician reviewer found that Molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC.  Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Therefore, FoundationOne CDx test performed on 12/31/19 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort.The physician reviewer found in this case, the medical records fail to indicate any diagnosis consistent with an IgG mediated food allergy to support an indication for the testing at issue. The current National Institutes of Health National Institute of Allergy and Infectious Disease expert panel states that IgG food testing is not validated (Boyce, et al). The Joint Task Force on Practice Parameters for the Allergy and Immunology also state that IgG food testing is not validated (Sampson, et al). As such, IgG food testing is not considered the standard of care in this clinical setting (Sicherer and Teuber). Thus, the IgG food sensitivity testing performed on 2/10/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 19-year-old female enrollee has requested reimbursement for substance use partial hospitalization services provided form 10/08/18 through 10/11/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. With regards to functional status, the records support a score of 2 due to an overall good functional level with appropriate activities of daily living. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability with stable psychiatric symptoms. With regards to level of stress of the recovery environment, the records support a score of 2 due to no mention of a stressful recovery environment. In terms of level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources. With regards to treatment and recovery history, the records support a score of 2 due to success in the treatment program with a good level of cooperation and stabilization of symptoms. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into her need for treatment. Thus, the patient has a composite score of 13. This score correlates with low intensity, community-based services. This patients presentation did not meet criteria for partial hospitalization program level of care. Therefore, substance use partial hospitalization that was provided from 10/08/18 through 10/11/18 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 62-year-old male enrollee has requested authorization and coverage for sacroiliac joint (SI) fusion/percutaneous spine fusion. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees SI joint disorder. The physician reviewer found that the selected procedure is a minimally invasive surgery which is more likely to be of benefit than any standard therapy for treatment of this patients SI dysfunction. The current medical literature pertaining to sacroiliac joint fusion demonstrates that surgical intervention for sacroiliac joint pain is beneficial in a subset of patients. Ledonio and colleagues studied 63 patients who underwent sacroiliac joint fusion with minimum one year follow-up. All patients had sacroiliac joint dysfunction confirmed by image guided intra-articular anesthetic sacroiliac joint injection and had failed non-operative treatment. The estimated blood loss, surgery time and length of stay favored the minimally invasive surgery sacroiliac fusion group. An article by Zaidi and colleagues demonstrates rates of excellent satisfaction determined by pain reduction, function, and quality of life ranged from 18%-100% with a mean of 54% in the open surgical cases and 56-100% with a mean of 84% in the minimally invasive surgery patients. The conclusion was that surgical intervention for sacroiliac joint pain was beneficial in a subset of patients. Although long-term results are still lacking, at this time there is sufficient data demonstrating that the requested sacroiliac joint fusion is likely to be more beneficial for treatment of the patients SI joint dysfunction than available standard modalities. In sum, the requested procedure is 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 62-year-old male enrollee has requested reimbursement for genetic testing performed on 
9/29/20. The Health Insurer has denied this request and reported that the services at issue were 
investigational for the evaluation of the enrollees medical condition. At issue is whether the 
services at issue were likely to have been more beneficial for evaluation of the enrollee's condition 
than  any  available  standard  therapy.  The  physician  reviewer  found  that  the  submitted 
documentation fails to demonstrate the superior efficacy of the services at issue. The initial 
diagnosis of squamous cell carcinoma is soon followed by a determination of the risk for distant 
metastasis or local recurrence. The various variables that figure into this determination involves 
the tumor size and evidence for perineural or lymphovascular invasion. The clinical features that 
figure into this include whether the lesion is recurrent or primary and is happening in the context 
of immunosuppression. There are also histologic parameters of the primary lesion and the depth 
of invasion that figure into the assessment of risk. The genetic analysis does not figure into the 
current National Comprehensive Cancer Network guidelines or in current publications. Therefore, 
the genetic testing performed on 9/29/20 was not likely to have been more beneficial than any 
available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 58-year-old male enrollee has requested authorization and coverage for intravenous immune globulin. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees myasthenia gravis. The physician reviewer found that Myasthenia gravis affects the neuromuscular junction. Patients can have weakness of the ocular, limb, respiratory, and bulbar muscles.  The nature of the pathogenesis (antibody mediated disease process) and the anatomical target can create clinical situations that are very diverse. Patients can have mild symptomatology with mild weakness or cosmetic changes to very severe life threatening clinical scenarios involving difficulty with breathing, ambulating, eating, and speaking. Treatment of myasthenia gravis is dependent on several factors including, but not limited to, the patients medical comorbidity, age, involvement of respiratory or bulbar muscles, progression, and severity. This patient has a form of myasthenia gravis that has been resistant to several therapies, including prednisone, plasmapharesis, azathioprine, mycophenolate mofetil, cyclosporine, and rituximab. Despite the significant number of medications the patient has failed, there are several therapeutic options that have shown to be effective in maintenance therapy for myasthenia gravis which have not been attempted, including tacrolimus, methotrexate, and cyclophosphamide. While intravenous immunoglobulin can be considered in severe refractory myasthenia gravis, there is a lack of evidence to suggest that intravenous immune globulin is more effective than these other agents which the patient has not tried. Therefore, intravenous immune globulin is not likely to be more effective than other 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: Experimental
Decision: Overturned

Summary Reviewer 2

A 59-year-old female enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan performed on 2/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees rigidity, lack of response to Sinemet trial, with suspected Parkinsons disease. The physician reviewer found that in one study investigating the negative predictive value of imaging in questioned Parkinsons disease, Marek and colleagues found that in non-DAT avid patients, the likelihood of progressing on to Parkinsons disease is negligible (Marek, et al). This indicates a reasonable test to exclude Parkinsons disease in the presence of questionable symptomatology. In a large cohort from Ravina and colleagues, the authors noted a diagnostic and predictive benefit to early baseline DAT SPECT imaging in the outcomes of patients followed. Subsequent scans were less effective in guiding management, but initial baseline imaging was found predictive. In the case presented, an initial baseline DAT SPECT scan to establish the diagnosis in initial therapy resistant weakness and tremor is both efficient and prudent in establishing therapy and helping to curtail future debilitation. Given these findings, the SPECT scan performed on 2/17/15 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, I have determined 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 2


The parent of a 12-year-old male enrollee has requested reimbursement and prospective authorization and coverage for intravenous immune globulin therapy. The Health Insurer has denied this request indicating that the services at issue were and are investigational for the treatment of the enrollees medical condition.The physician reviewer found the medical literature supports the use of IVIG in patients with autoimmune encephalitis. In this patients case, he had pre-existing autoimmune disease in the form of Hashimotos thyroiditis, and then developed acute symptoms associated with autoimmune encephalitis. He has an allergy to prednisone, and has thus far responded well to sequential administration of IVIG. His specialists have recommended a prolonged course of IVIG to prevent recurrence of this complication of his autoimmune disease. Autoimmune encephalitis, or antibody-mediated encephalitis, affects children and adults, and is emerging as a more common cause of encephalopathy in these populations. Current treatment strategies involve removal of existing antibodies, in the form of intravenous immunoglobulins and plasmapheresis, as well as immunosuppression to decrease production of antibodies. The first-line therapy then includes IVIG, parenteral steroids, and plasmapheresis, with some potential additional benefit from second-line immunosuppressant therapies. For all these reasons, the services at issue were and are likely to be more beneficial for treatment of this patients autoimmune encephalitis than any available standard modality.For the reasons set forth above, the services at issue were and 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 64-year-old male enrollee has requested reimbursement for assay of vitamin D performed on 8/08/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollee, who has a history of hyperlipidemia. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The clinical manifestations of vitamin D deficiency depend upon the severity and duration of the deficiency. The majority of patients with moderate to mild vitamin D deficiency are asymptomatic. In the setting of severe vitamin D deficiency, there can be hypocalcemia which leads to bone disorders. Patient groups who are at risk for vitamin D insufficiency include those who have dark skin or are obese, those taking medications that accelerate the metabolism of vitamin D, hospitalized or institutionalized people or those who have limited effective sun exposure. Other people at high risk include those with osteoporosis or malabsorption, including inflammatory bowel disease and celiac disease.  Screening of the general population is not recommended. In this case, the patient did not have chronic medical conditions that would cause vitamin D deficiency. Thus, assay of vitamin D performed on 8/08/18 was not medically necessary for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
The patient is a 13-year-old male who presented to his provider on 3/4/22. The patients parent 
has requested authorization and coverage for Nutropin AQ Nusprin 10 injector. The physician 
reviewer found that at issue is whether Nutropin AQ Nusprin 10 injector is medically necessary 
for the treatment of this patient. The submitted documentation does not support the medical 
necessity of the requested medication. Somatotropin may be indicated for pediatric use for 
specific conditions, including pediatric growth hormone deficiency so long as epiphyses, or 
growth  plates,  remain  open.  Generally  accepted  diagnostic  criteria  define  isolated  growth 
hormone deficiency as either growth velocity with a z-score below 2.0 standard deviation score 
(SDS) or a height z-score below 2.25 SDS, along with subnormal response to two standard 
growth hormone stimulation tests. In this case, the patients clinical presentation and course are 
most consistent with normal variations of growth and development and with the familial pattern 
of growth and development. The records do not document that this patient meets the generally 
accepted indications for growth hormone therapy. The submitted records also did not discuss 
brain magnetic resonance imaging (MRI), generally performed  prior to initiation of somatotropin 
in children and adolescents to exclude intracranial lesions, or direct measurements of parental 
heights. Based on all of these factors, the medication is not indicated. Therefore, Nutropin AQ 
Nusprin 10 injector is not medically necessary for the treatment of this patient.