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

Summary Reviewer 

A 60-year-old male enrollee has requested reimbursement for Oncotype DX Genomic Prostate Score performed on 5/16/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) recommends that men who are status post biopsy with low or favorable intermediate risk disease may consider the use of the Oncotype DX testing. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of NCCN risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy, and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays.  It is considered a standard of care in guiding treatment decision making. Therefore, the Oncotype DX Genomic Prostate Score performed on 5/16/19 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


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 in this clinical setting, there is support for IVIG in treatment of this patients medical condition. The patient has been treated with IVIG with associated improvement in symptoms. A medical review of IVIG and encephalitis revealed use of immunoglobulins and plasmapheresis as alternatives to steroids for Hashimotos encephalopathy in a case series (Yu et al). IVIG has seen associated with improvement in children with acute encephalitis syndrome complicated by myocarditis (Bhatt et al). In a recently published review of autoimmune encephalitis, it was stated that the repertoire of autoimmune encephalitis in children is different from that of adults. The younger the child the more difficult it is to recognize specific autoimmune encephalitis syndrome, which suggests that guidelines for pediatric autoimmune encephalitis will be more dependent on antibody and other ancillary tests than the syndrome-based guidelines in this Position Paper (Graus et al). In a study of acute immune-mediated and infectious encephalitis in 28 children, immune-modulating therapies were given to 28 patients. The authors wrote that although evidence is limited to retrospective series and case reports, the best available data suggests that early treatment with intravenous immunoglobulin or plasmapheresis, or both, followed by long-term immunosuppression is associated with better outcomes.  A study regarding off-label medication use in 677 children admitted to an academic pediatric critical care unit published that FDA-prescribing guidelines were available in less than 35% of the commonly prescribed medications (Hsu and Brazelton). Given the above-referenced medical literature, IVIG was and is likely to be more efficacious for treatment of the patients autoimmune encephalitis symptoms than any available standard therapy. Therefore, 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 41-year-old male enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) provided from 10/02/20 through 11/20/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that depression is a common mental disorder and a leading cause of morbidity. Approximately 30% of patients do not respond to standard medication and/or psychotherapy. The evidence on repetitive TMS (rTMS) for depression is adequate, although the clinical response can be variable. The majority of patients who achieve remission following rTMS continue to stay in remission at the end of one year. Perera and colleagues noted, aTMS therapy is recommended for use as a subsequent option in patients who previously benefited from an acute treatment course and are experiencing a recurrence of their illness (continuation or maintenance).a This consensus statement also recommended that aTMS can be reintroduced in patients who are relapsing into depression after initially responding to TMS treatment.a Given that the patientas depressive symptoms improved by over 50% during this course of TMS, the records document that the requested treatment is superior to the standard of care, which the patient has previously tried and not responded to. Therefore, TMS provided from 10/02/20 through 11/20/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 58-year-old female enrollee has requested authorization and coverage for an electric hospital bed (E0265). The Health Insurer has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollee, who has been diagnosed with muscle weakness and reduced mobility. The physician reviewer found that the patient has a history of alcohol abuse and liver cirrhosis, conditions associated with encephalopathy due to multiple mechanisms of action. The patient also had muscle weakness and significant mobility impairments. She was requiring total assistance for transfers by mechanical lift transfer device. She had positioning needs due to her respiratory condition, gastrostomy tube feeds, pressure injury and susceptibility for skin and soft tissue breakdown. These mobility needs could have been met with a semi-electric hospital bed with an appropriate mattress surface. A total electric hospital bed also includes electric height adjustment, which could be necessary for individuals who require this feature for independent transfers into and out of the bed.  In the current case, this feature was obviated by the patients use of a mechanical lift device for dependent transfers. Electric height adjustment on a hospital bed is otherwise considered a convenience feature. Thus, the requested electric hospital bed (E0265) is not medically necessary for the treatment of this patient. Therefore, the requested equipment 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 2


A 48-year-old female enrollee has requested reimbursement for a breast tomosynthesis that was performed on 11/25/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for purposes of the enrollees breast cancer screening. The physician reviewer found per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Medical studies and peer reviewed literature support the use of tomosynthesis in this clinical setting.  For these reasons, the tomosynthesis used to screen this patient for breast cancer was likely to be more beneficial 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: Upheld

Summary Reviewer 3

A 63-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 3/08/19. 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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individualas melanoma cells. It then classifies that melanoma based on the five-year risk of metastasis. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is unknown if the DecisionDx-Melanoma assay can be used to make clinical decisions. Thus, DecisionDx-Melanoma testing provided on 3/08/19 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a 10-year-old male enrollee has requested reimbursement and prospective authorization and coverage for intensive behavioral therapies (33 hours per week of H2019) provided from 1/03/19 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees autism. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The VB-MAPP report indicated that the patient was performing at the approximate level of an 18 to 30 month old. The records documented aggressive behavior, elopement, and pica/mouthing. While aggression is relatively low, elopement and pica/mouthing occurred more frequently and can be dangerous. It is important that the patient continue to receive ABA treatment to decrease the frequency of these behaviors and learn appropriate alternative/replacement behaviors. Further, the listed goals throughout the authorization plan highlight the need for a more intense level of service. In this patients case, the results of the VB-MAPP assessment, frequency of problem behavior, and barriers assessment supported 33 hours of CPT code H2019 per week. ABA therapy is the most evidence-based treatment for individuals on the autism spectrum. The medical evidence supports the services at issue in this clinical setting. Therefore, intensive behavioral therapies (33 hours per week of H2019) provided from 1/03/19 forward were and are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
A 59-year-old male enrollee has requested authorization and coverage for deep brain stimulation. 
The Health Insurer has denied this request and reported that the requested service is investigational 
for the treatment of the enrollees Parkinsons disease. The physician reviewer found that DBS is 
indicated in cases of Parkinson's Disease in which motor fluctuations and dyskinesias are present. 
DBS is approved by the U.S. Food and Drug Administration (FDA) for the treatment of Parkinson's 
Disease. In this case, the patient has motor fluctuations and dyskinesias despite best medical 
management,  which  is  standard  management  for  Parkinsons  Disease.  The  patient  is  now  experiencing the known limitations and side effects of standard medication management. In this 
clinical setting, the requested service is likely to be more beneficial than standard medical therapy 
as DBS reduces motor fluctuations secondary to medications. Therefore, deep brain stimulation is 
likely to be more beneficial for treatment of the patients condition than any available standard 
therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3 
 
A 56-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 6/04/21. 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 Melanoma is a cancer that is curable in its earliest stages. 
Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph 
nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes 
may be amenable to excision but this suggests a high-risk for the development of metastatic disease 
in the future. Such patients may be observed or treated with interferon-alpha. The data on  DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node 
biopsy. There has also been some lack of consistency between various genes being used as 
biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment 
algorithm  beyond  standard  staging  techniques.  Therefore,  DecisionDx-Melanoma  testing 
performed on 6/04/21 was not likely to have been more beneficial than any available standard 
therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a seven-year-old male enrollee has requested authorization and coverage for Nutropin AQ Nuspin 10. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has a low body mass index, even for DiGeorge syndrome. There is no evidence that the poor weight gain has been addressed properly, as this can lead to growth failure. There is no evidence of what the bone age is on the present notes. This patient had an actual growth velocity of 4 cm per year in the last year, which is reassuring. Patients with DiGeorge syndrome can have hypothyroidism which can also lead to short stature. There is no evidence from the current notes that this has been ruled out. At this time, the medical records do not establish that Nutropin AQ NuSpin 10 is medically indicated. Therefore, Nutropin AQ NuSpin 10 is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 47-year-old male enrollee has requested reimbursement for the Oncotype Dx Colon Cancer Assay provided on 2/14/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees rectosigmoid cancer. The physician reviewer found that it has not been established in the medical literature whether molecular markers are useful in treatment decisions and prognosis in patients with colon cancer. While an assay may have the ability to help estimate a patients risk of recurrence, whether such increased risk can be overcome by adjuvant chemotherapy remains unclear. In addition, the National Comprehensive Cancer Network (NCCN) guidelines state that there are insufficient data to recommend the use of multi-gene assays, such as the Oncotype DX assay, to determine adjuvant therapy. Thus, the Oncotype DX Colon Cancer Assay provided on 2/14/18 was not likely to be more beneficial for evaluation of this 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 2


A 20-year-old male enrollee has requested reimbursement for the Anser IFX testing provided on 10/26/15. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease status post resection. The physician reviewer found that in this case, Anser IFX was ordered to determine the patients infliximab level and whether antibodies to infliximab were present. However, the use of Anser IFX to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease. The presence of antibodies does not necessarily result in loss of response to infliximab, nor have clear infliximab levels been established (Steenholdt, et al). Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response (Vande Casteele, et al; Nanda, et al). A recent study concluded that prospective evaluation of the value of measuring serum concentrations of infliximab should be performed before these data can be included in patient management strategies (Adedokun, et al). One study, with some patients undergoing dose intensification following initial non-response, showed no difference in serum levels of infliximab between patients who responded to dose intensification versus those who did not (Pariente, et al). Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing (Vande Casteele, et al). Based on the current clinical literature, the Anser IFX testing provided on 10/26/15 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: Overturned

Summary Reviewer 

The patient is a 56-year-old female with a history of elevated liver enzymes, which she attributes to alcohol intake. Ultrasound of the abdomen on 7/01/19 showed heterogeneously increased liver echogenicity, likely hepatic steatosis, and a 4.0 cm hepatic cyst, which was previously 3.0 cm. Magnetic resonance imaging (MRI) of the abdomen with and without contrast was performed on 9/09/19. The physician reviewer found that per the American College of Radiology, the recommended test for liver lesions greater than 1 cm in size found on ultrasound is an MRI with and without contrast. This is supported by guidelines from the American Association for the Study of Liver Disease, which state that MRI can determine whether such lesions are hepatocellular carcinoma. The risk of hepatocellular carcinoma is increased in the setting of hepatic steatosis, even in the absence of cirrhosis, and the large liver lesion seen on ultrasound was concerning for hepatocellular carcinoma. Therefore, MRI of the abdomen, without contrast, performed on 9/09/19 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 60-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 7/01/20. 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 prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individualas melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami reported on 217 cases, with good correlation between DecisionDx-Melanoma testing class and prognosis in patients undergoing sentinel node biopsy. It is not known how the five-year DecisionDx-Melanoma testing data compares to the ten-year Balch data. It is not known if the DecisionDx-Melanoma testing data can be used to make clinical decisions. The National Comprehensive Cancer Network does not recommend the test to make decisions. Therefore, DecisionDx-Melanoma testing performed on 7/01/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index adds a bit to these statistics. DecisionDx-Melanoma testing is a 31-gene assay of the genomic-molecular abnormalities within an individualas melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not known if the DecisionDx-Melanoma classification can be used to make clinical decisions. The decision about whether or not to do a sentinel node is based on thickness and other pathologic features, not DecisionDx-Melanoma classification. The decision about adjuvant therapy is generally based on the results of the sentinel node biopsy, if performed, and other pathologic features. The National Comprehensive Cancer Network does not recommend the use of the DecisionDx-Melanoma assay to make clinical 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 33-year-old female enrollee has requested reimbursement for laboratory services (82746, 82607 and 82306) provided on 6/05/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting. Kennel and colleagues noted, Even when using a conservative definition of vitamin D deficiency, many patients routinely encountered in clinical practice will be deficient in vitamin D. The authors reported, It has been suggested that clinicians should routinely test for hypovitaminosis D in patients with musculoskeletal symptoms, such as bone pain, myalgias, and generalized weakness, because these symptoms are often associated with hypovitaminosis D and might be misdiagnosed as fibromyalgia, chronic fatigue, age-related weakness, or even depression. Green noted, There are numerous known causes of deficiency of folate or vitamin B-12. In some situations, such as chronic generalized malabsorption or malnutrition, deficiencies of both vitamins may coexist. Hunt and colleagues noted that vitamin B12 deficiency occurs at high rates in South Asia. Also, the risk of vitamin B12 deficiency is higher in individuals who consume alcohol heavily. In this case, the patient is of South Asian descent and had recently returned to the United States after living there for an extended period. He reported that he had been self-medicating with alcohol. He reported shoulder pain, anxiety, and low mood, and also reported being treated with weekly vitamin D supplements in the past. For all of the above reasons, it was medically appropriate for the patients provider to check levels of vitamin D, B12, and folate at the initial visit. Therefore, laboratory services (82746, 82607 and 82306) provided on 6/05/19 were medically necessary for the evaluation of this patient.