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

Summary  
The patient is a 53-year-old female with a history of primary melanoma of the cervix with an 
erythroblastic oncogene B (ERBB)2 V777L mutation. In a letter dated 12/13/22, the provider 
reported that the patient was diagnosed in April 2022. The records noted that the patient had 
undergone initial treatment with four cycles of ipilimumab with nivolumab. The Health Insurer 
has denied the requested medication as not medically necessary. This denial is the subject of this 
appeal and determination. The physician reviewer found that the records document that this patient 
presents with a history of primary melanoma of the cervix with an erythroblastic oncogene B 
(ERBB)2 V777L mutation. The patients provider has recommended treatment with Tukysa. Per 
the  National  Comprehensive  Cancer  Network  (NCCN)  guidelines  for  melanoma,  mucosal 
melanoma should be treated as diseases distinct from cutaneous melanoma, with care tailored to 
the individual patient. The U.S. Food and Drug Administration (FDA) has approved Tukysa for 
the treatment of patients with HER2 positive breast cancer or HER2 positive colon cancer, to be 
taken in combination with other agents. However, there is a lack of FDA approved indication or 
support for use of Tukysa for use as monotherapy in the treatment of this patients cancer. Strickler 
and colleagues reported that studies are ongoing to evaluate the efficacy of Tukysa as monotherapy 
and to validate the reported findings from their trial. Overall, there is a lack of data to suggest that 
Tukysa as single agent therapy is safe and effective in this patients clinical setting. All told, the 
requested Tukysa (tucatinib) 150 mg #120/30 days is not medically necessary for treatment of this 
patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The patient is a 28-year-old female who presented to her provider on 12/27/22. The patient has 
requested reimbursement for knee orthosis on 12/27/22. The Health Insurer has denied this 
request and reported that the equipment at issue was not medically necessary for the treatment 
of this patient. The physician reviewer found that the submitted documentation does not support 
the medical necessity of the equipment at issue. The use of functional ACL bracing following ACL 
reconstruction has been debated over the past several years. In a systematic review of functional 
bracing  after  ACL  reconstruction,  Lowe  and  colleagues  report,  The  effectiveness  of 
postoperative  functional  bracing  following  ACL  reconstruction  remains  elusive.  Some  data 
suggest that functional bracing may have some benefit with regard to in vivo knee kinematics 
and may offer increased protection of the implanted graft after ACL reconstruction without 
sacrificing  function,  range  of  motion,  or  proprioception.  However,  limited  evidence  exists 
supporting the use of routine functional bracing to decrease the rate of reinjury after ACL 
reconstruction. Smith and colleagues conclude, Biomechanical and clinical evidence suggests 
current functional bracing technologies do not sufficiently restore normal biomechanics to the 
ACL-deficient knee, protect the reconstructed ACL, and improve long-term patient outcomes. 
Yang and colleagues note, Knee bracing does not appear to improve the clinical outcomes on 
the function and stability for ACL-reconstructed knees. Thus, bracing for patients treated with 
ACL reconstruction should not be recommended routinely. Andrade and colleagues report, 
Immediate knee mobilisation and strength/neuromuscular training should be used. Continuous 
passive  motion  and  functional  bracing  should  be  eschewed.  Given  that  current  medical 
literature  does not  recommend continued  passive  motion and post-operative bracing, the 
equipment at issue was not medically indicated. Therefore, knee orthosis on 12/27/22 was not 
medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 52-year-old male enrollee has requested reimbursement for a wearable cardioverter defibrillator provided on 1/24/19. The Health Insurer has denied this request indicating that the device at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer found that in this circumstance, there is potential for recovery of left ventricular function over time with medical therapy. There was no documented indication for immediate placement of a defibrillator, such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest.  Placement of a prophylactic defibrillator is not recommended until a period of time greater than 90 days where continued left ventricular dysfunction is documented to persist despite appropriate treatment. A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. Recent retrospective trials in patients with newly diagnosed non-ischemic cardiomyopathy have not demonstrated benefit with prophylactic wearable defibrillators. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. In sum, the wearable cardioverter defibrillator provided on 1/24/19 was not likely to have been superior over other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 55-year-old female enrollee has requested reimbursement for the spinal surgery and one day inpatient services provided on 1/8/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees low back pain with radiation down the right leg. The physician reviewer found that per the North American Spine Society (NASS) recommendations, this patient meets the criteria for the spinal surgery performed and one day inpatient services provided on 1/8/17. Lumbar fusion is indicated for spinal stenosis with qualifying criteria, when appropriate. These criteria include cases in which decompression will likely result in iatrogenic instability, such as foraminal stenosis, during which greater than 50% of the facet joint will be removed to adequately decompress the exiting nerve root. Per the NASS guidelines, the criteria for lumbar laminotomy include a pattern of radiculopathy/neurogenic claudication explained by imaging findings and 6-12 weeks of non-operative treatment. In this patient, the criteria have been satisfied as there is proper documentation of 6-12 weeks of non-operative treatment being performed. In addition, based upon the spinal stenosis at the foraminal level, decompression would have resulted in iatrogenic instability and therefore the requested stabilization at the L4-S1 level was medically necessary. All told, the records provided for review support the medical necessity of the spinal surgery and one day inpatient services provided on 1/8/17 for treatment of this patients low back pain and lumbar radiculopathy. Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 57-year-old female enrollee has requested reimbursement for anesthesia services provided on 2/06/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who underwent colonoscopy. The physician reviewer found that according to the American Society of Anesthesiologists guideline for anesthesia care during endoscopic procedures, monitored anesthesia care is warranted in patients with a history of failed moderate sedation, which applies to this case of a patient with a seizure after moderate sedation in the past. According to other published criteria, allergies to sedation medications are a reason for use of monitored anesthesia care. According to the most recent guidelines from the American Society for Gastrointestinal Endoscopy, monitored anesthesia care is recommended for previously anticipated intolerance to standard sedatives, as in this case of a seizure after midazolam. Thus, anesthesia services provided on 2/06/18 were medically necessary 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

The parent of a 14-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 10/7/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the Prometheus Anser IFX diagnostic testing performed on 10/7/14 was likely to be more effective for this patient than other available treatment options. The testing at issue has become the standard of care for providers to determine whether the patient will benefit from the drug. Prometheus Anser IFX testing informs the provider if the serum levels of drug are in the range to be beneficial and effective or if they have antibodies that could potentially lead to a reaction or failure to respond. This helps guide the provider in dosing or may lead to discontinuation of the drug if the patient is not likely to benefit from the medication. This prevents the patient from having a flare-up and also prevents potential side effects of a drug the patient may not benefit from. In this case, the patient appeared to be losing response to Remicade and Prometheus Anser IFX testing allowed for the provider to determine if antibodies are present or if the patient needs a higher dose of the medication to prevent from a flare-up with further consequences. Therefore, the Prometheus Anser IFX testing was appropriate for the management of the patients Crohns disease and 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 57-year-old female with a history of lumbar degenerative changes and adjacent segment disease following a fusion at L4-5 with herniations L2 to S1 and degenerative spondylolisthesis at L3-4. The patient has requested authorization and coverage for laminectomy PLIF surgery and two (2) inpatient bed days. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient has a history of lumbar degenerative changes and adjacent segment disease following a fusion at L4-5. The records document low back pain. She has chronic herniations and neural foraminal stenosis at multiple levels from L2 to S1 and degenerative spondylolisthesis at L3-4.  A review of the current medical literature with regard to the laminectomy/decompression and PLIF indicates that it remains safe and effective, with a high percentage of pain relief and achieving a solid bony fusion. Therefore, laminectomy PLIF surgery and two (2) inpatient bed days are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 48-year-old female enrollee has requested reimbursement for lab testing (Factor V Leiden genetic testing) provided on 12/16/14. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  There is a lack of current medical recommendation from national societies, including the American College of Obstetrics and Gynecology (ACOG), for such screening before the prescribing or use of HRT. Such testing in the general population has not been shown to impact on the safety or risk of using HRT across the population. The ACOG Bulletin on prevention of deep vein thrombosis (DVT) addresses who would benefit from such testing stating Because of the high prevalence of the Factor V Leiden mutation in the Caucasian population, all patients who are not Hispanic, Asian, or African American and have a history of DVT may be tested. In non-Caucasian patients, the decision to test should be individualized. Patients with histories of extensive or recurrent thrombosis or family histories of thrombosis may have the Factor V Leiden mutation in combination with another congenital or acquired disorder. In this case, the patient was asymptomatic with no personal or family history of thrombosis. The testing performed was not indicated or likely to be more beneficial for evaluation of the patients medical condition than other modalities. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 59-year-old male enrollee has requested reimbursement for gene testing performed on 3/9/15. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that gene testing performed on 3/9/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the initial biopsy report was determined to be indeterminate. The Afirma testing showed a suspicious lesion, which was a determining factor in delineating the further course of action to assess whether a surgical procedure was warranted. Afirma testing is considered standard protocol on fine needle aspirations performed on thyroid nodules. In sum, the testing at issue 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: Upheld

Summary Reviewer 2 
A 36-year-old female insured has requested reimbursement for laser hair removal performed on 
10/25/22. A review of the record indicates that the insured was diagnosed with hidradenitis 
suppurativa at the axillae and groin two years ago, which worsened with pregnancy. The Health 
Insurer indicates the services at issue were considered investigational for the treatment of the 
insured's medical condition. Therefore, the Health Insurer has denied reimbursement for the 
services at issue. This denial is the subject of this appeal and determination. The physician reviewer 
found that there are several options are available for the treatment of patients with hidradenitis 
suppurativa, including medical and surgical modalities. However, there is a paucity of studies 
comparing medical treatments to surgical treatments. According to the United States and Canadian 
Hidradenitis  Suppurativa  Foundations,  oral  antibiotics  such  as  clindamycin,  rifampicin,  and 
ertapenem, other medical treatments such as infliximab and adalimumab, and surgical treatments 
such as laser therapy and surgical excision, are all considered standard therapies for the treatment 
of patients with hidradenitis suppurativa (Alikhan, et al.; Goldburg, et al.). In this case, the patient 
has a history of hidradenitis suppurativa that was treated with laser hair removal. While laser hair 
removal is a treatment option, the current medical literature has not established its benefits over 
other standard therapies, including oral antibiotics. There is a lack of documentation indicating 
that the patient tried oral antibiotics such as clindamycin, rifampicin, and ertapenem. For these  reasons, the laser hair removal performed on 10/25/22 was not likely to be more beneficial for the 
treatment of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is a 70-year-old male. The patient has requested reimbursement for foreign claim  
Mexico, ambulance transportation on 4/30/21. The physician reviewer found that submitted 
documentation supports that the patient received emergency medical services on 4/30/21. In 
this case, the patient had a life-threatening injury with significant risk of morbidity and mortality 
resulting in neurologic deficits that had the potential to worsen and become irreversible with any 
treatment delay. The patient had an emergent neurosurgical procedure performed for the same 
reasons. He did not have access to neurosurgical care to receive his life and brain-saving 
treatment at the hospital in Mexico. Prompt treatment and the use of an ambulance in this 
emergency situation was justified and necessary. Non-medical transportation in this clinical 
setting would have posed a substantial risk of potential worsening of morbidity and potential 
mortality as patients with worsening neurologic deficits, as in this case, require close medical 
monitoring  both  during  the  hospital  stay  and  when  being  transported  between  hospitals. 
Therefore, foreign claim  Mexico, ambulance transportation on 4/30/21 was an emergency 
medical service and medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 13-year-old male with extreme short stature and growth hormone deficiency (GHD). The patients parent has requested authorization and coverage for Norditropin Flexpro 30 mg/3 ml. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that the current medical evidence supports the requested medication in this patients case. His height is severely compromised, and he has been growing poorly. Per the growth chart, the patient has experienced growth failure over several years. The growth velocity is less than the third percentile of normal range. In sum, the patient has demonstrated growth failure, low IGF-1 levels and predicted adult height less than mid-parental height. His presentation is consistent with growth hormone deficiency with a severe delay in bone age. In this setting, growth hormone is a standard of care. Therefore, Norditropin Flexpro 30 mg/3 ml is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 54-year-old male has requested reimbursement for Anser VDZ test provided on 7/17/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found that there is insufficient medical evidence to support the effectiveness of Anser VDZ compared with conventional courses of action in the management ulcerative colitis. The published studies including the use of anti-Entyvio antibodies and serum levels are small, retrospective, and/or observational rather than controlled (in regards to the study of using Entyvio levels and anti-Entyvio antibody levels) in nature, preventing firm conclusions about cause and effect. Additionally, the antibodies can be transient. Controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with ulcerative colitis compared with conventional management. For these reasons, Anser VDZ test provided on 7/17/17 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 37-year-old female enrollee has requested authorization and coverage for Gilenya. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees multiple sclerosis. The physician reviewer found that Gilenya is a disease-modifying therapy approved by the U.S. Food and Drug Administration (FDA) for the treatment of multiple sclerosis. One of the major challenges of treating patients with multiple sclerosis is prescribing a regimen that is effective and also regimen with which the patient will comply. Even if a therapy is effective, if a patient does not comply then it is unlikely the therapy will be effective.  In this patients case, Gilenya is a therapy that is effective and one which the patient is compliant as it fits her lifestyle.  There is sufficient support for the requested medication in this clinical setting.  All told, Gilenya is medically indicated for the treatment of this patient.  Therefore, the requested medication is 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  63-year-old  female  enrollee  has  requested  reimbursement  for  FoundationOne  CDx  TM 
comprehensive genomic profiling test performed on 1/26/21. 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 understanding the molecular 
drivers  of  cancer  progression  and  metastases  is  an  area  of  ongoing  and  active  research, 
predominantly driven by the goal of identifying specific genomic aberrations that may ultimately 
result in individualized cancer treatment. In addition to likely providing prognostic information, 
the value of next generation sequencing to predict candidates for specific mutation-driven 
treatment holds promise. Patients with inflammatory and metastatic breast cancers benefit from 
next  generation  sequencing  to  identify  markers  that  may  indicate  benefit  from  targeted 
treatment or clinical trials. For hormone receptor-positive/HER2-negative breast cancer, testing 
for PIK3CA mutations with tumor or liquid biopsy to identify candidates for alpelisib plus 
fulvestrant  should  be performed.  In  addition, molecular  markers  can indicate response  to 
immunotherapy. The medical evidence supports the services at issue in this setting. Therefore, 
FoundationOne CDx TM comprehensive genomic profiling test performed on 1/26/21 was likely 
to have been more beneficial than any available standard therapy.