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

Summary Reviewer 

The patient is a 28-year-old transgender female who is seeking facial feminization surgery.  The Health Insurer has denied coverage for facial feminization surgery. Per the Health Insurer, the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the purpose of medically necessary facial feminization surgery is to relieve gender dysphoria. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life. World Professional Association for Transgender Health, Inc. (WPATH) states, Non-genital surgical proceduresnotably facial feminization surgeryare often of greater practical significance in the patients daily life than reconstruction of the genitals. WPATH notes, These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. The current medical evidence supports the requested services in this patients case. Therefore, the requested facial feminization surgery is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 51-year-old male has requested reimbursement for gene expression profiling performed on 5/14/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. There is a lack of evidence from the literature that tailored follow-up according to these test results has an impact on long-term outcomes. Furthermore, prospective randomized studies to determine recurrence risk is lacking for this test. The medical evidence has not determined the superior efficacy of the services at issue. Thus, gene expression profiling performed on 5/14/17 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 72-year-old male enrollee has requested reimbursement for brachytherapy performed on 7/5/17 through 7/31/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees basal and squamous cell cancer. The physician reviewer found that there is support in the medical literature for the services at issue. Radiation therapy is an option for the initial management of small, well defined, primary cutaneous squamous cell carcinomas. It is primarily reserved for older patients and patients who are not surgical candidates due long term side effects. According to the documentation provided, this patient meets the standard criteria. Brachytherapy is the standard of care for treating this patients primary cutaneous squamous cell carcinomas. In sum, the brachytherapy performed on 7/5/17 through 7/31/17 was medically necessary for the treatment of this patients medical condition. Therefore, for the reasons stated above, 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: Upheld

Summary Reviewer 2

A 49-year-old female enrollee has requested reimbursement for Guardant360 CDx testing performed on 3/22/21. 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 the NCCN guidelines recommend next generation sequencing (NGS) for pancreatic cancer patients. However, testing on tumor tissue is preferred. This patient did undergo NGS sequencing of the tumor removed at initial surgery and has had liquid NGS with Guardant360 in the past as well. Although serial liquid biopsy has been shown to help predict prognosis, its impact on therapeutic decision-making has not been demonstrated. Its role in the treatment of pancreatic cancer has yet to be defined. There is a lack of support for the use of serial liquid NGS at this time. Therefore, Guardant360 CDx testing performed on 3/22/21 was not likely to have been more beneficial for evaluation of the patientas condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 20-year-old female enrollee has requested reimbursement for residential treatment provided from 6/21/17 through 7/26/17. 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 that the submitted documentation fails to demonstrate the medical necessity of the services at issue. On 6/21/17, the patient did not have any suicidal ideation. She attended and participated in her groups and therapy sessions. She continued to have symptoms of distractibility and irritability. Per the records, the patient was compliant with her medications. She was cooperative with the staff and did not have any aggressive behavior. The patient interacted with her peers in a positive manner. The records do not demonstrate that the patient was a danger to herself or others during the dates of service in dispute. Based on the submitted documentation, the patient could have been treated in a less restrictive environment. Therefore, residential treatment provided from 6/21/17 through 7/26/17 was not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 53-year-old male enrollee has requested reimbursement for emergency department visit (99285) provided on 2/18/19. 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 CPT code 99284 describes an emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patients and/or familys needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function. This level of billing would be an appropriate level of service in this patients case. All told, 99285 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a seven-year-old female enrollee has requested authorization and coverage for Avastin (bevacizumab). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees glioblastoma multiforme. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested medication. Brainstem gliomas are aggressive and chemotherapy options are limited. These tumors are very rare so the studies available in the medical literature are small and limited. Nevertheless, medical studies indicate that Avastin use is safe and effective. Importantly, Avastin is being used upfront along with radiation therapy where it may also have steroid-sparing function. Given the lack of standard options available to this patient, Avastin is clinically indicated. Therefore, the request for Avastin is medically necessary and appropriate in this patients case. For the reasons provided, the requested medication is 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 22-year-old male enrollee has requested reimbursement for substance use intensive outpatient program services from 10/14/16 through 10/28/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. Based on the documentation provided, the patient had been transitioned into a sober living housing. He participated in groups though he was noted at times to be disruptive and sarcastic. The appeal letter stated that the patient required IOP due to grieving over the loss of his father, abandonment issues from his mother, and to address obsessive thoughts. The documentation does not state if any of these issues were addressed in the group sessions. The majority of the group sessions focused on substance treatment, sobriety, and coping with stressors. There was no documentation that the patient had any suicidal or homicidal ideation. There was no documentation that the patient was medically ill and required frequent supervision. By 10/14/16, the records indicate that the patient could have gone to community 12 step program meetings and achieved the same result. The patient could have been treated in a less restrictive environment as an outpatient with the patient attending community 12 step program meetings and working with his sponsor. Therefore, IOP services provided from 10/14/16 through 10/28/16 were not medically necessary for treatment of this patients medical condition. Based on the reasons stated above, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

The parent of a 16-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 12/13/13. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found in general, 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-TNF agent or switching to a non-anti-TNF agent based on clinical observation in lieu of Anser IFX testing. In this patients case, the medical records submitted for review do not support acute loss of therapeutic response nor acute disease flare. There are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. In addition, 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. In sum, the testing at issue was not clinically indicated and not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The patient is a 53-year-old female with history of melanoma. The provider ordered genetic testing to assess the metastatic risk of the patients 0.4 mm Breslow depth melanoma affecting the right medial thigh.  The patient has requested reimbursement for the genetic testing performed on 9/15/17. The Health Insurer denied this request for reimbursement on the basis that the services at issue were considered investigational for the evaluation of this patients medical condition.  The use of this type of genetic testing is not considered a standard of care in this clinical setting. The National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting (Coit, et al). As such, the utilization of DecisionDx-Melanoma gene assay is not expected to affect the treatment or health outcome of this patients melanoma. In sum, the genetic testing performed on 9/15/17 was not likely to have been superior over the standard treatment options for the evaluation of this patients medical condition.  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 3

A 48-year-old female enrollee has requested reimbursement for genetic testing performed by Myriad Laboratories on 10/4/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for breast or ovarian cancer syndrome. The physician reviewer found that this patient has several close relatives with cancers suggestive of a genetic cause for malignancy. The patient may have inherited a mutation from her paternal side, given her sister and cousins with breast cancer. Based on this, she meets the National Comprehensive Cancer Network (NCCN) guidelines for genetic testing. The largest studies reporting on the outcomes of multigene testing indicate that among women tested in clinical settings, about 5-10% have a BRCA1 or BRCA2 mutation, and about 4-7% have a harmful mutation in another gene associated with high to moderate risks of breast and/or ovarian cancer. Thus, the genetic testing performed by Myriad Laboratories performed on 10/4/17 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: Experimental
Decision: Upheld

Summary Reviewer 1

A 21-year-old male enrollee has requested reimbursement for polymerase chain reaction testing performed on 6/07/19. 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 the patient had complaints of aching in his penis and perineum.  He was initially treated on 2/18/19 with one gram of azithromycin for these symptoms. Testing for gonorrhea and chlamydia was negative. On 4/11/19, he was seen again with a history of aching in his perineum and penis and difficulty in maintaining an erection. He was given three weeks of doxycycline. His symptoms persisted, and he had a tender prostate on physical examination. He was given ciprofloxacin for three weeks. The patients symptoms improved, but then recurred. After referral to a urologist, broad spectrum screening by polymerase chain reaction testing was ordered. The medical evidence does not support the services at issue in this clinical setting. The testing was not directed at potential pathogens that cause prostatitis. Moreover, there is a lack of evidence in the medical literature that polymerase chain reaction screening is an effective or appropriate method to use in identifying the causes of prostatic symptoms. The patients complaint of being unable to sustain an erection is not related to prostatic infection and suggests other factors might be present. Therefore, polymerase chain reaction testing performed on 6/07/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 3


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 tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor. In this particular case, the use of tomosynthesis was as a problem solving tool. On her initial mammogram, only two views of each breast were obtained.  It was after a questionable abnormality was detected that she was recalled for additional imaging including a breast sonogram and a tomosynthesis exam.  This is an appropriate use of tomosynthesis.  In addition, she has heterogeneously dense breasts.  For the reasons provided, 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 2


The parent of a four-year-old female enrollee has requested reimbursement for chromosomal microarray (CMA) genetic testing performed on 9/16/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation the enrollees developmental delays. The physician reviewer found that the medical literature supports chromosomal microarray as the first-line for the evaluation of suspected genetic abnormalities. Coulter and colleagues showed that CMA influences medical management in a majority of the patients where an abnormality was found. Moreover, CMA is critical when clinical features suggestive of Williams syndrome are found (Sharma, et al). All told, CMA is the standard of care for evaluation of children with developmental delay. In this case, the patients positive CMA supports the chromosomal microarray genetic testing performed on 9/16/15 was likely to be more beneficial for evaluation of the patients developmental delay 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: Experimental
Decision: Overturned

Summary Reviewer 2
A 63-year-old male enrollee has requested reimbursement for dopamine transporter imaging with a single proton emission computed tomography (DaT SPECT) scan performed on 8/24/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who presented with persistent hand tremors. The physician reviewer found that DaT is an acceptable diagnostic technique for the determination of Parkinsons disease. In patients where the cause of tremor is not known or is likely to be caused by other diagnoses, such as essential tremor, the use of a DaT scan can be helpful in determining the correct diagnosis. This scan has been widely used by movement disorders specialists and general neurologists when there is a question of whether a patient has Parkinsons disease. Medical studies have shown that the early diagnosis of Parkinsons disease allows for better control of symptoms and allows the patient to access available resources sooner. Accordingly, this patient benefited significantly from having the scan performed in order to confirm the cause of his tremor. All told, DaT SPECT scan performed on 8/24/16 was likely to have been more effective than other available modalities in evaluating this patient.  Based upon the information set forth above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is a 47-year-old male with a periodic fever syndrome clinically consistent with a 
diagnosis of tumor necrosis factor associated periodic syndrome (TRAPS). The patient has 
requested authorization and coverage for llaris (canakinumab) injection 150 mg/ml, #1/56 day. 
The physician reviewer found that the submitted documentation supports the medical necessity 
of the requested medication. TRAPS is a rare autoinflammatory disorder caused by genetic 
variations in the tumor necrosis factor receptor 1 (TNFR1) gene. Symptoms of TRAPS can include 
recurrent fever, myalgias and chest pain. A diagnosis of TRAPS is established based on history 
and physical examination after other causes of fever, such as infection, malignancy and other 
autoimmune diseases, have been excluded. There are no specific laboratory tests, outside of 
genetic testing, that can assist with establishing the diagnosis of TRAPS, and genetic testing is not 
consistently conclusive. Preventing recurrent attacks from uncontrolled TRAPS is important in 
reducing the risk of amyloidosis development, a complication of this disorder. Treatment with 
TRAPS includes NSAIDs, which only result in symptom relief in 75% of patients and do not 
effectively  control  disease  related  inflammation.  Corticosteroids  can  provide  a  short-term 
reduction in inflammation for patients with TRAPS. IL-1 inhibition with canakinumab is effective 
and is currently the only approved treatment for TRAPS. De Benedetti and colleagues conducted 
a randomized trial  to evaluate the efficacy and safety of canakinumab in patients with the 
following  periodic  fever  syndromes:  colchicine-resistant  familial  Mediterranean  fever, 
mevalonate kinase deficiency, and TRAPS. At week 16, significantly more patients with TRAPS 
receiving canakinumab had a complete treatment response compared to placebo, 45% versus 
8%. In addition, the inclusion of patients whose canakinumab dose was increased to 300 mg every 
four weeks led to a complete treatment response in 73% of study participants with TRAPS.  
Furthermore, after the 16-week period, disease control was maintained in 53% of persons with 
TRAPS using canakinumab every eight weeks. In this case, the patient did not have an adequate 
treatment response to NSAIDs or prednisone in the past. Treatment with canakinumab was noted 
to be effective therapy for this patients TRAPS per the submitted medical record. As indicated 
by the randomized trial above, canakinumab is effective and appropriate for the treatment of 
this patients disorder. Further delay of appropriate treatment with canakinumab can have 
serious health consequences for this patient, as the development of amyloidosis is a serious 
complication of this disease. Therefore, llaris (canakinumab) injection 150 mg/ml, #1/56 day is 
medically necessary for the treatment of this patient.