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

Summary Reviewer 1


A 53-year-old female enrollee has requested reimbursement for the homocysteine testing performed on 3/9/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees peripheral neuropathy. The physician reviewer found that this patient presented with a focal peripheral nerve symptom in the distribution of the right superficial peroneal nerve with no sensory findings on exam, normal EMG, and mild changes on MRI. Overall, the patients history and findings do not support a diagnosis of peripheral neuropathy, and the laboratory testing performed would not be expected to show any related abnormalities. Homocysteine levels are checked when a patients B12 and/or methylmalonic acid levels are equivocal. However, routine use of methylmalonic acid and homocysteine is not considered the standard of care for the work-up of peripheral neuropathy, as methylmalonic acid is the usual confirmatory test and homocysteine is generally not helpful. As B12 deficiency can be diagnosed with standard testing with use of B12 and methylmalonic acid, and homocysteine is obtained if initial testing is equivocal, the homocysteine testing performed on 3/9/16 was not more likely to lead to a proper diagnosis over standard testing. 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 53-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees prostate cancer. The physician reviewer found that according to the National Comprehensive Cancer Network (NCCN) guidelines, proton beam radiation therapy has not been demonstrated to provide superior health outcomes when compared to standard available radiation therapy for management of prostate cancer. In addition, proton beam radiation therapy is currently the subject of ongoing clinical trials. Overall, there is insufficient high quality clinical evidence to make conclusions about the relative safety and efficacy of proton beam radiation as compared with standard of care photon intensity modulated radiation therapy (IMRT). All told, the requested proton beam radiation therapy is not medically necessary for treatment of this patients prostate cancer. Based on the foregoing discussion, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 29-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 2/25/16.  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 the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  There is insufficient evidence to support the use of drug level monitoring for biologics in this clinical setting. The quality of evidence is considered to be low due to the fact that studies to date have primarily been retrospective.  High-quality, randomized controlled trials are lacking.  The evidence to date does not demonstrate that this strategy leads to better clinical outcomes.  Therefore, Anser IFX testing performed on 2/25/16 was not likely to have been more effective than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 14-year-old female enrollee has requested reimbursement for mental health treatment provided from 7/28/16 through 8/10/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  During the dates of service in dispute, the patient was still requiring up to several hours of one-on-one staff time in order to perform routine activities of daily living.  She continued to need prompts for getting up in the morning, going to bed and completing showering and washing her face and hair in an acceptable amount of time.  The amount of staff time she required would not be provided at the partial hospitalization program level of care.  More importantly, she needed treatment in getting out of bed, preparing to shower and other morning hygiene routines.  This patient required staff to be in the bathroom with her, which would not have occurred in a less intensive level of care.  This symptom also had to be addressed, as it was the symptom causing the greatest degree of functional impairment in her life.  All told, for mental health treatment provided from 7/28/16 through 8/10/16 were indicated for the treatment of this patient.  Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 33-year-old female enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) test and Factor V Leiden performed on 5/17/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of deep vein thrombosis and pulmonary embolism. The physician reviewer found that a prior personal history of deep vein thrombosis/pulmonary embolism, especially in the setting of oral contraceptive use or pregnancy, is a significant risk factor for thrombosis during pregnancy. Since no records were available regarding prior laboratory work-up for inherited thrombophilias, Factor V Leiden testing was medically appropriate. However, the medical evidence does not support MTHFR testing in this setting since MTHFR mutations have not been associated with venous thromboembolism either in pregnant or non-pregnant patients. Therefore, Factor V Leiden testing performed on 5/17/18 was likely to have been of greater benefit than other methods of evaluating this patient. However, the superior efficacy of MTHFR has not been established. Based upon the information set forth above, a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 32-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 9/24/19. 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 there is a lack of support for the services at issue in this clinical setting. Prognostic gene expression profiling (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 melanoma and a higher proportion of false-positive result, GEP testing should not guide clinical decision making in this group. This patient has a small good prognosis lesion based on pathology. Commercially available GEPs, such as DecisionDx-Melanoma testing, are marketed as being able to classify cutaneous melanoma into separate categories used on risk of metastasis. However, it remains unclear where these GEP platforms provide clinically actionable prognostic information when used in addition to or in comparison with known cliniopathologic factors or multivariate nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. Various (mostly retrospective) studies of prognostic GEP testing suggest its role as an independent predictor of worse outcome, although not superior to Breslow thickness or sentinel lymph node status. It remains unclear whether this GEP profile is reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation studies are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Therefore, DecisionDx-Melanoma testing performed on 9/24/19 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 63-year-old female enrollee has requested authorization and coverage for an iris prosthesis. 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 traumatic aniridia can lead to photophobia and disfigurement, both of which need to be addressed. The main options are contact lens or an iris prosthesis. In this case, the patient has already tried contact lens. There is sufficient support for the use of an iris prosthesis in this setting, and these services have been approved by the U.S. Food and Drug Administration (FDA). In this patientas case, an iris prosthesis is likely to be more beneficial than contact lens. A contact lens does not fully restore cosmesis and carries a risk of infection. Therefore, the requested iris prosthesis is likely to be more beneficial for the treatment of this patient than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 48-year-old female enrollee has requested reimbursement for the lab testing provided on 11/28/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees migraines, mild memory impairment, and prior syncope. The physician reviewer found that this patient presented with a common problem that is migraine with aura. An extensive and expensive battery of testing for thrombophilia was ordered based on the providers concern about vascular risk factors. However, there is no mention of standard testing for vascular risk factors such as cholesterol levels, nor is there standard coagulation testing that might indicate an abnormal potential for thrombophilia. There is also no history of any coagulation issues in the past such as recurrent miscarriage, deep vein thrombosis, stroke, or myocardial infarction. As noted in the peer-reviewed medical literature, there is currently no role for the thrombophilia testing ordered by the provider in this clinical setting. Specifically, routine screening of homocysteine, Leiden V, and methylenetetrahydrofolate reductase (MTHFR) is not recommended due to positive testing in the asymptomatic general population. Many publications have guidelines for use of these tests, however this patient has none of the indications for thrombophilia testing. Thus, the lab testing provided on 11/28/16 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 64-year-old female enrollee has requested reimbursement for ChemoFx Assay testing performed on 9/30/13.  The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees ovarian cancer.The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the testing at issue. In vitro drug testing on patients tumor cells prior to applying chemotherapy is an attractive idea but it is difficult to put into clinical use. The most thorough evaluation of these technologies was performed by the American Society of Clinical Oncology. In their review of this technology the panel concluded that in vitro drug testing should be limited to clinical trials (Schrag, et al). Moreover, the Physicians Data Query of the National Cancer Institute does not specifically recommend the ChemoFx Assay to direct therapy. In the clinical setting of newly diagnosed ovarian cancer there is extensive clinical data supporting the first-line use of paclitaxel and carboplatin. For the reasons provided, ChemoFx Assay testing performed on 9/30/13 was not medically necessary for evaluation of this patients medical condition. Therefore, the Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 48-year-old male enrollee has requested authorization and coverage for cervical artificial discectomy and second level cervical discectomy.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that the requested services are not likely to be more effective for this patient than other available options. Based on the documentation submitted for review, the patient has ill- defined neck pain and upper extremity symptoms. There is a lack of evidence demonstrating cervical radiculopathy (Bono) with dermatomal and myotomal symptoms and findings matching that diagnosis with correlation of radiographic findings. In addition, his pain generator has not been defined. There is a lack of conclusive evidence, including physical findings to implicate the C5-6 or the C6-7 level as the patients source of pain. Although the study by Davis and colleagues is encouraging, there is a lack of support in the peer-reviewed literature demonstrating the long term safety and effectiveness of Mobi-C. All told, the requested surgery 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: Experimental
Decision: Overturned

Summary Reviewer 2

A 44-year-old female enrollee has requested authorization and coverage for the Intracept procedure. 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 there is sufficient support for the requested services in this clinical setting. Khalil and colleagues performed a prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. The authors concluded that minimally invasive radiofrequency ablation of the basivertebral nerve led to significant improvement of pain and function at three months in patients with chronic vertebrogenic related low back pain. Fischgrund and colleagues concluded that patients treated with radiofrequency ablation of the basivertebral nerve for chronic low back pain exhibited sustained clinical benefits in the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) pain scores, and maintained high responder rates at two years following treatment. Basivertebral nerve ablation appears to be a durable, minimally invasive treatment for the relief of chronic low back pain. She has failed to respond to nonsurgical management. Therefore, the requested Intracept procedure is likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer

The patient is a 42-year-old female with a history of chronic low back pain. The progress notes dated 10/7/17, document a six month history with pain in the lower back radiating into both lower extremities.  Associated symptoms included numbness, tingling and loss of bladder/bowel control.  The pain was reported to be 8 out of 10 and worsening. The patient reported that any level of movement aggravated her low back pain.  Medications for pain relief were not effective.  Other conservative treatments, which have been tried and failed, include chiropractic, physical therapy, topical, and exercise program. On examination, transfers were difficult; range of motion was limited and magnetic resonance imaging (MRI) scan revealed degenerative disc disease at L5-S1 with a 2 mm bulge and possible annular tear on the right. The follow up progress notes document continuing worsening of pain, primarily in the lower back on the right side consistent with the MRI findings of the right side involvement.  The provider discussed treatment options and the patient elected the surgical option in light of the degree of disability.  The provider is recommending anterior lumbar interbody fusion at L5-S1 with anterior instrumentation, L5-S1 cage with interbody fusion with harvest of iliac crest autograft versus bone morphogenic protein. The patient has requested authorization and coverage for autograft spine surgery. The Health Insurer denied this request and reported that the requested services are not medically not necessary. This denial is the subject of this appeal and determination. There is support in the medical literature for the medical necessity of the requested services in this clinical setting. Anterior lumbar interbody fusion is associated with higher success rates compared with posterolateral lumbar fusion in patients with degenerative changes of the lumbar spine including those with instability. There is moderate evidence that for patients with lumbar degenerative disc disease without instability a standalone anterior lumbar interbody fusion has better clinical outcomes than the anterior lumbar interbody fusion plus instrumented open posterior lumbar fusion. With regard to the type of interbody spacer used, the proposed autograft has a high fusion rate. In this case, the patient has severe pain that has not responded to conservative treatment. The patients pain is interfering with her activities of daily living. The provider has documented discogenic origin for the pain.  Based on medical literature and guidelines, the requested anterior lumbar interbody fusion procedure is medically necessary for treatment of this patients medical condition.   Therefore, for the reasons stated above, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 31-year-old male enrollee has requested reimbursement for respiratory sleep studies performed on 6/8/14, 6/17/14 and 6/19/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees sleep apnea. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. There was no documentation of hypersomnia. Hypersomnia is the cornerstone for a diagnosis of clinically significant sleep apnea. In addition, his Epworth Sleepiness score was normal at 4. There was no reported morning headache. The patient reported snoring and was slightly overweight. However, this is not an indication for a sleep study. Based on the medical records submitted and the peer-reviewed literature, the respiratory sleep studies performed on 6/8/14, 6/17/14 and 6/19/14 were not medically necessary for evaluation of the patients medical condition. 
For the reasons provided, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 63-year-old male enrollee has requested authorization and coverage for laparoscopy, surgical, esophagogastric fundoplasty (LINX). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found LINX Reflux Management System (LINX) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient has a diagnosis of persistent chronic GERD that has persisted despite treatment with proton pump inhibitor dosing and behavioral modification. The patient has a DeMeester score of 35 with evidence of Barretts per esophagogastroduodenoscopy (EGD). Treatment with the LINX procedure is indicated due to his persistent acid reflux and resulting in damage that will likely predispose him to adenocarcinoma. For the reasons provided above, the requested services are likely to be more beneficial for treatment of the patients medical condition than other modalities.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: Overturned

Summary Reviewer 2


A 56-year-old male enrollee has requested reimbursement for positron emission tomography (PET) scan performed on 1/19/16.  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 patients case.  The records indicate that the patient has metastatic prostate cancer.  The PET scan performed on 1/19/16 was likely to have been more efficacious than other methods of evaluation.  The medical literature supports this modality as superior to bone scan with regards to detection of prostate cancer bone metastases within the spine.  The PET scan performed is the most reliable investigational tool when there is high index of suspicion for osseous metastases.  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.