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

Summary Reviewer 3

A 37-year-old female has requested authorization and coverage for Gammagard liquid 10% vial. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollee, who has a history of recurrent pregnancy loss.  The physician reviewer found that IVIG treatment has been proposed as a treatment for the diagnosis of recurrent miscarriage due to immunologic causes. The etiologies for recurrent miscarriage may include chromosomal, uterine structural, ovulatory and immune factors or combinations of these factors. The treatments for immune factors, and especially their efficacy, are currently highly controversial when assessed for the standard of care. IVIG is one of these proposed treatments. Although a few early non-randomized, uncontrolled studies may have shown modest benefit in properly characterized patients with repeated pregnancy loss, most others that have used randomized controlled methods have not. Thus, there is no clear efficacy as yet shown per the current literature. The American Society for Reproductive Medicine, in its Practice Bulletin, stated treatment with IVIG has also been proposed for unexplained pregnancy loss. However, several trials and meta-analyses concluded that IVIG is ineffective for primary recurrent pregnancy loss; thus, this treatment is not recommended. Thus, the requested Gammagard liquid 10% vial is not likely to be more effective than other treatment options. Based upon the information set forth above, the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 62-year-old male enrollee has requested reimbursement for blood test (protein biomarker tests or 4Kscore) provided on 10/29/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for developing metastases. The physician reviewer found that the 4Kscore test is a blood test which may be used to calculate an individual patients percent risk for aggressive prostate cancer on prostate biopsy. The 4Kscore test is intended to be used for patients with an abnormal prostate-specific antigen (PSA) and/or abnormal digital rectal examination who are being considered for initial or repeat prostate biopsy to identify the risk of high-grade prostate cancer. The test results provide percent risk for detecting high-grade prostate cancer on subsequent biopsy. The National Comprehensive Cancer Network guidelines recommend consideration of 4Kscore test for patients with prostate-specific antigen (PSA) levels greater than 3 ng/mL who have not yet had a biopsy. While 4Kscore may eventually have a role in reducing unnecessary biopsies, there are insufficient data on clinical outcomes to currently support routine use in screening men for prostate cancer. Hence, use of 4Kscore is not considered a clinically appropriate and generally accepted standard of care in routine screening for prostate cancer in men. The value of 4Kscore testing in men with prostate nodularity is largely unknown. In sum, the blood test (protein biomarker tests or 4Kscore) performed on 10/29/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 52-year-old male enrollee has requested reimbursement for gene testing (gene expression profiling) performed on 10/31/18. 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 to 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 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. Thus, gene testing (gene expression profiling) performed on 10/31/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 62-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/02/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found the medical evidence supports the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  Based upon the information set forth above, the service 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 

A 33-year-old male enrollee has requested authorization and coverage for Epidiolex 100 mg/mL solution. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The patient has been on multiple anti-epileptic medications, including Keppra, gabapentin and Lamictal. He continues to demonstrate seizure activity. In cases where patients are refractory to traditional therapies, the use of cannabidiol has demonstrated significant benefit in controlling seizure activity. As this patient has not responded to traditional therapies, the use of Epidiolex is medically appropriate. Therefore, Epidiolex 100 mg/mL solution is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 38-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/13/15.  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 there is sufficient support for the services at issue in this clinical setting.  According to 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 noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  The medical literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  All told, breast tomosynthesis performed on 7/13/15 was 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 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 3 
 
The parent of a 16-year-old female enrollee has requested reimbursement for autonomic 
testing performed on 8/19/20. The Health Insurer has denied this request and reported that the 
services at issue were investigational for the evaluation of the enrollees medical condition. The 
physician reviewer found that the patient reported several symptoms consistent with 
autonomic dysfunction including positional dizziness, balance problems, urinary incontinence, 
skin changes, and others. In addition, in this case, the patient had skin color changes and other 
symptoms, such as swelling and burning pain, that could be consistent with a small fiber 
neuropathy.  The spectrum of disorders that can lead to this presentation is broad and includes 
disorders in the POTS spectrum, including POTS or orthostatic intolerance to disorders caused 
by autonomic failure, including small fiber neuropathies, degenerative neurological disorders or 
innate central disorders of autonomic dysregulation. Per current standards of care, autonomic 
reflex testing may be indicated. Testing includes tilt table testing, which stresses the bodys 
autonomic vascular systems. In addition, small fiber tests, such as quantitative sudomotor axon 
reflex test (QSART) or quantitative axon reflex sweat test (QSWEAT) may be performed to 
determine if there is autonomic failure due to neuropathies.  Axon-reflex-based small fiber test 
of sudomotor, vasomotor, and pilomotor function is a well described test for evaluation of 
post-ganglionic function in cases where there is a suspicion of such dysfunction.  Though it is 
not widely used outside of specialized centers (due to technical demands), it is currently 
considered a standard of care test. Autonomic reflex testing is considered a standard of care for 
patients with autonomic symptoms. There is no other effective way of evaluating for and 
diagnosing certain autonomic disorders. Therefore, autonomic testing performed on 8/19/20 
was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 60-year-old male enrollee has requested authorization and coverage for 18F-NaF positron emission tomography/computed tomography (PET/CT) scan. The Health Insurer has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that based upon the recommendations of the National Oncologic PET Registry, the Centers for Medicare and Medicaid Services (CMS) revised its guidelines concerning coverage for PET scans in patients with solid tumors allowing up to three scans in each patient for diagnosis, staging and surveillance. While the use of this compound has proven to be of use in prostate cancer, the re-approval of 18F-NaF as a pharmaceutical has proven of greater benefit to patients with rising PSA levels where bone metastases are possible. The reason is the proven marked increased sensitivity of the technique compared to standard technetium bone scans in the detection and localization of skeletal metastatic deposits. In this patient with a rising PSA after radical prostatectomy, the possibility of subtle skeletal metastatic disease is possible and the requested 18F-NaF PET/CT scan is the most sensitive means with which to evaluate this patient.  Based upon the information set forth above, I have determined the requested diagnostic procedure is 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 

A 59-year-old male enrollee has requested authorization and coverage for Testim (testosterone gel 1%). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hypogonadism. The physician reviewer found that low testosterone can lead to complications including reduced libido, erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis, depressed mood and fatigue (Dandona and Rosenberg). For these reasons, many providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dL (Nieschlag, et al). The general target level for testosterone ranges from 350 to 750 ng/dL, which is the range for healthy, androgen-sufficient adult men. Testosterone levels should be monitored three to six months after initiation of treatment in order to assure that the patients testosterone level is optimal and the dose of testosterone replacement therapy should be adjusted accordingly (Rivas, et al). Given these findings, the requested Testim (testosterone gel 1%) is medically necessary for treatment of this patients hypogonadism. Based on the foregoing discussion, 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 30-year-old male enrollee has requested reimbursement for partial hospitalization program (PHP) chemical dependency services provided from 11/24/15 through 12/8/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse and bipolar disorder.   The physician reviewer found that this patients records do not include an admitting psychiatric or psychosocial evaluation with description of the patients social and sober support. In addition, there is no mental status examination or urine drug screening. On 12/3/15, the provider discontinued Abilify, leaving him on Seroquel and Paxil 37.5 mg. The records suggest the patient was psychiatrically stable as group therapy notes state that he was able to participate, concentrate, and maintain appropriate behavior, and there was no indication of medical instability. Overall, there is limited information regarding patients substance abuse or bipolar diagnoses. According to the American Psychiatric Association (APA) guidelines, the PHP chemical dependency services provided from 11/24/15 through 12/8/15 were not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, 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: Overturned

Summary Reviewer 

A 47-year-old male enrollee has requested authorization and coverage for Dupixent (dupilumab). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees atopic dermatitis. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. This patient has a chronic history of moderate to severe atopic dermatitis which has been unresponsive to treatment with numerous medium to ultrapotent topical steroids, topical immunomodulators and intramuscular steroids. Dupixent is a U.S. Food and Drug Administration (FDA) approved injectable biologic for the treatment of moderate to severe atopic dermatitis.  Given that the patient has had a lifelong history of moderate to severe atopic dermatitis and has failed management with topical and systemic steroids as well as topical immune modulators, Dupixent is medically appropriate. The long-term risks of continued use of topical or systemic steroids has been well-established. Thus, Dupixent (dupilumab) is medically necessary 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 54-year-old female who was diagnosed with a high-grade triple negative left-sided breast cancer. The patient has requested authorization and coverage for proton beam therapy. 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 guidelines do not endorse the routine use of proton therapy in the treatment of breast cancer. There is a lack of data to suggest that proton beam therapy would be beneficial in this case or that it would be associated with less side effects than standard treatment with photons. The standard treatment in this case would be with chemotherapy, followed by surgery, followed by radiation with photons. Furthermore, consensus group guidelines do not support the use of proton therapy in this setting. In the vast majority of cases, intensity modulated radiation or three-dimensional conformal techniques with photons is able to achieve an acceptable cardiac and lung dose. Furthermore, treatments using deep inspiratory breath hold, which move the heart away from the chest wall, are also associated with very low cardiac doses in patients receiving radiation for breast cancer. In this case, although the comparison planning shows lower heart and lung doses with the proton plan, the standard plan with photons is not representative of typical cardiac or lung doses with intensity modulation or breath hold techniques. There is a lack of level I evidence to support the use of proton therapy for the treatment of breast cancer. Therefore, the requested proton beam therapy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 27-year-old male enrollee has requested reimbursement and prospective authorization and coverage for continued sub-acute inpatient care from 7/26/17 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollee who is diagnosed with a brain injury.The physician reviewer found there is support for the services at issue in this clinical setting. The documented therapy and physician notes show that there has been improvement in this patients clinical status during his time at sub-acute inpatient care facility. Specifically, the documentation reports improvements in standing, heel to floor distance, tracking, head control, increased wheelchair tolerance, development of spontaneous swallowing, and command following.  Despite his traumatic brain injury, this patients young age and overall good health are positive prognosticators. Taking into account the documented improvement in the patients medical status with the therapy he is receiving and his positive prognosticators, the services at issue were and are medically necessary for the treatment of his medical condition. Therefore, continued sub-acute inpatient care from 7/26/17 forward was and is medically necessary for the treatment of this patients medical condition.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 53-year-old female enrollee has requested reimbursement for OVA1 testing performed on 5/19/15. 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 patient was seen for postmenopausal bleeding, and an ultrasound showed an incidental 1.3 cm simple ovarian cyst.  Simple ovarian cysts, especially when this small, are common, even in early menopause, and considered functional, which means they come and go.  This one was actually smaller than on a prior ultrasound.  In this case, those findings made the likelihood of any ovarian pathology, and particularly ovarian cancer, very low.  Her provider recommended surgery for the bleeding.  In this case, no surgery was indicated for the cyst, and none was planned.  The use of OVA1 has been approved for a very narrow indication, to determine whether a patient should be referred to a gynecologic oncologist for ovarian surgery that is already planned so that appropriate staging and surgical management can take place if ovarian cancer is found.  This patient had a simple small ovarian cyst with no indication of possible ovarian cancer, and no surgery was planned or indicated for the cyst.  The use of OVA1 was not appropriate based on current standards, and was not needed to assist with her clinical management.  Thus, OVA1 testing performed on 5/19/15 was not likely to have been superior over 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: Experimental
Decision: Upheld

Summary Reviewer 1


An 18-year-old male has requested reimbursement for Anser IFX testing performed on 7/09/15.  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 there is sufficient support for the services at issue in this clinical setting.  This patient was losing response to the biologic treatment.  Rather than empirically dose escalate the patient, the provider recommended Anser IFX testing.  This testing determined that dose escalation would be futile.  This allowed for a rapid switch to another more beneficial agent.  In sum, Anser IFX testing provided on 7/09/15 was likely to have been superior over other methods of evaluating this patient.  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 1


A 51-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 5/23/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who reported bilateral breast tenderness. The physician reviewer found there is sufficient support for the service at issue in this clinical setting.  Skaane and colleagues noted 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 indicated integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  The literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, breast tomosynthesis performed on 5/23/16 was likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the service 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.