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

Summary Reviewer 1

A 51-year-old female has requested reimbursement for genetic testing performed on 4/13/18. 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 the patient is a 51-year-old female who was diagnosed with melanoma of the right medial distal pretibial region. Pathology report from 6/06/16 showed a malignant melanoma, superficial spreading type, Clarks level IV. There was no ulceration, necrosis or regression. DecisionDx-Melanoma testing was performed on 4/13/18. The patient has requested reimbursement for genetic testing performed on 4/13/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. This patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. Therefore, genetic testing performed on 4/13/18 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

A 38-year-old male enrollee has requested reimbursement for polymerase chain reaction testing for gastrointestinal pathogen panel performed on 12/16/19. 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 most cases of acute diarrhea are due to infections and are self-limited. The major causes of acute infectious diarrhea include viruses, bacteria, and protozoa. For most patients who do not have severe illness or high-risk comorbidities, it is reasonable to continue expectant management for several days without microbiologic stool testing (e.g. polymerase chain reaction multiplex molecular panel tests). Per the Infectious Diseases Society of America (IDSA) guidelines, immediate testing is indicated with severe disease defined as follows: profuse watery diarrhea with signs of hypovolemia; passage of greater than six unformed stools per 24 hours; severe abdominal pain; need for hospitalization; other signs or symptoms concerning for inflammatory diarrhea; bloody diarrhea; passage of many small volume stools containing blood and mucus; temperature greater than or equal to 38.5AoC (101.3AoF). In this case, the submitted records do not document the severity and duration of symptoms. The clinical notes provided do not support that the patient met criteria for the services at issue. Therefore, polymerase chain reaction testing for gastrointestinal pathogen panel performed on 12/16/19 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 26-year-old male enrollee has requested authorization and coverage for Xyrem. 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 patients history of excessive daytime sleepiness and the MSLT with normal polysomnography are consistent with the narcolepsy diagnosis. The interpreting sleep physician explained that the patient met the criteria in the first four naps. It is usually acceptable not to conduct the fifth nap if the first four naps are consistent with the diagnosis. Thus, the records confirm the diagnosis of narcolepsy. In this patients case, it appears as if a stimulant alone is not enough to control the patients symptoms. Untreated or undertreated narcolepsy can lead to accidents. Therefore, Xyrem is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 63-year-old male who was evaluated with DecisionDx-Melanoma testing on 5/13/19. Pathology from 4/10/19 from a left forearm biopsy showed melanoma, Clarks level II, 0.36 mm thickness. The physician reviewer found that this patient had an early stage melanoma. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to help differentiate benign from malignant neoplasms, or to help distinguish melanomas at low-risk versus high-risk for metastasis, routine genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. There is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Therefore, tumor biomarker or gene expression classifier test performed on 5/13/19 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 20-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 8/14/18. 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 the medical evidence has not demonstrated the superior efficacy of vaginitis panel testing using polymerase chain reaction technology. Although these methods have high sensitivity and specificity, including a shorter turn-around time than culture, the testing offers no proven benefit over standard culture in symptomatic women. Furthermore, there is a lack of evidence on the clinical utility and impact of polymerase chain reaction testing for vaginitis. There is a lack of studies showing that this testing leads to better patient management decisions or better health outcomes. Studies of diagnostic accuracy alone are inadequate, especially because most symptomatic women can be diagnosed with a standard work-up and/or a trial of empiric therapy. Thus, polymerase chain reaction testing performed on 8/14/18 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 55-year-old female enrollee has requested authorization and coverage for corticotropin (Acthar Gel). The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that the records document refractory rheumatoid arthritis and type 2 diabetes. She has tried and failed multiple medications, including nonsteroidal anti-inflammatory drugs (NSAIDs), high-dose intravenous corticosteroids, methotrexate, Enbrel, Arava, Plaquenil, Rituxan, Actemra, Xeljanz, Cimzia, Humira, Orencia, Imuran, Simponi, and Remicade. She has failed multiple tumor necrosis factor inhibitors and multiple biologic agents and continues to have active rheumatoid arthritis. In this case, the use of Acthar Gel would not be considered off-label, as Acthar Gel is approved for short-term use in rheumatological conditions, and this request is for six to eight weeks of therapy. She would need to be bridged to another medication. Short-term use would be consistent with current labeling and as a bridge to more definitive therapy. In sum, corticotropin (Acthar Gel) is likely to be more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 66-year-old male enrollee has requested authorization and coverage for Praluent. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has been diagnosed with hyperlipidemia and cardiovascular disease. The physician reviewer found that the documentation provided does not support the requested medication in this clinical setting. Based on the records, the patient has been diagnosed with hyperlipidemia and documented coronary disease. In this setting, medical therapy is indicated to achieve a goal reduction in LDL cholesterol to less than 70 mg/dl according to current guidelines.  Since this was documented to be achieved with Vytorin 10/80 alone, the medical necessity for the addition of a proprotein convertase subtilisin/kexin type-9 (PCSK9) inhibitor, such as Praluent, is not supported by the documentation.  PCSK9 inhibitors are approved for patients with familial hyperlipidemia or documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol. The medical literature suggests that additional LDL lowering on top of that achieved with Vytorin is not medically necessary since the LDL cholesterol was already less than 70 mg/dl without the addition of a PCSK9 inhibitor. Accordingly, Praluent is not medically necessary for the treatment of this patients medical condition. Therefore, based on the above, the requested medication is 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 46-year-old female enrollee has requested authorization and coverage for CPT 19316 performed on 10/24/18. 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 the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had evidence of significant symptomatic macromastia, and she had failed conservative management. Based on the documentation provided, she was a candidate for bilateral breast reduction based on non-resolving functional impairment. She underwent this procedure on 10/24/18. The operative note was consistent with a standard breast reduction and not solely a mastopexy. Generally, standard breast reductions include a breast lift as an integral part of the procedure and would not be considered a separate procedure. Based on the documentation provided, this patient underwent a bilateral breast reduction and not solely a mastopexy. An additional mastopexy would not be considered as a separate procedure, but an integral portion to the breast reduction. Therefore, the Health Insurers denial was appropriate. Thus, mastopexy (CPT 19316) performed on 10/24/18 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 23-year-old female with a history of depression. She has undergone pharmacological management of her depression since 2019. Medication trials have included Prozac, Wellbutrin, venlafaxine, Zoloft, Lamictal and Ability. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. Given the severity of her symptoms and functional impairment, TMS is medically indicated. Currently, TMS is indicated for the acute phase of major depression. This patient has failed over four different agents of two different classes. She has failed CBT, which is an evidence-based psychotherapy for major depressive disorder. The TMS Society Consensus Review recommends TMS for the acute phase of severe depression, which she is currently experiencing. Therefore, TMS is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

The patient is a 61-year-old female with a diagnosis of melanoma measuring 2.65 mm in depth. Her provider submitted a tissue sample for molecular genetic testing with the DecisionDx to determine the risk of metastasis for this tumor. The patient has requested reimbursement for the DecisionDx melanoma assay provided on 6/30/14. The Health Insurer has denied this request indicating that the testing at issue was considered investigational. The DecisionDx melanoma assay tests the tissue genetics of the melanoma to help stratify whether melanoma is high risk for metastasis. The DecisionDx test has shown some accuracy in melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Overall, there is not enough published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx melanoma assay provided on 6/30/14 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: Experimental
Decision: Overturned

Summary Reviewer 3

The parent of a 12-year-old female enrollee has requested reimbursement for fecal calprotectin testing provided on 7/17/15. 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 that Fecal calprotectin is a noninvasive laboratory test which is frequently used in clinical practice to evaluate for the presence of intestinal inflammation. In addition to its utility in screening for inflammatory bowel disease, it also has utility in evaluating for flares or recurrent inflammation in the setting of known inflammatory bowel disease. This test can be particularly helpful in a situation where a patients symptoms may be due to another cause, to assess for presence of deep remission in a patient who is asymptomatic, and to evaluate for response to treatment in a patient with atypical or mild symptoms at diagnosis. Fecal calprotectin testing has become a standard measurement in the practice of pediatric gastroenterology, as it often allows the physician to avoid or defer a repeat colonoscopy on a child. All told, there is adequate peer-reviewed medical data demonstrating that the fecal calprotectin testing provided on 7/17/15 was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined 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 56-year-old male enrollee has requested reimbursement for the Cologuard test provided on 12/1/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found that the Cologuard test provided on 12/1/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Cologuard is U.S. Food and Drug Administration (FDA) approved to test for colon cancer, proved 92% sensitive for detection of colon cancer, and can detect most adenomas with high-grade dysplasia (Imperiale, et al). The limited evidence for Cologuard reports that 154 patients would have to be screened to find one cancer using colonoscopy, versus 166 patients using Cologuard, thus cancers may be missed by Cologuard (Imperiale, et al). Additionally, the evidence of the impact of this information on patient care or health outcomes is lacking. Although Cologuard is able to determine that cancer has already developed, it cannot detect or remove polyps or precancerous lesions. Health outcomes using Cologuard have not been compared over the long-term with other screening methods for colon cancer. In addition, there is a lack of consensus in clinical guidelines and peer-reviewed literature to support that Cologuard has a positive impact on health outcomes. Given the limited support in the peer-reviewed medical literature, Cologuard was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 43-year-old female enrollee has requested authorization and coverage for Contrave. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees morbid obesity. The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. According to the documentation provided, this patient falls into a class III (high risk) obesity. She has not had success with diet or exercise, or with the weight loss medication Belviq.  She also has multiple comorbidities such as hypertension, borderline diabetes, and obstructive sleep apnea (Jensen, et al). Contrave is U.S. Food and Drug Administration approved for chronic weight management in patients with BMI over 30 (package insert).  Guidelines for pharmacological management of obesity released in 2015 by the Endocrine Society state that patients who have a history of being unable to successfully lose and maintain weight are candidates for weight loss medications (Apovian, et al). Specifically, pharmacotherapy is recommended in patients with BMI higher than 30 kg/m2 (or 27 if comorbidities are present). This patient had a BMI of 45.2 kg/m2 in May 2017. Studies have shown 8.2% weight loss at one year, with approximately 40% of patients losing more than 10% of their weight (Sherman, et al).  For these reasons, the request for Contrave is supported as medically necessary for the treatment of the patients medical condition.Therefore, for the reasons stated above, 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 2

The parent of a 14-year-old female enrollee has requested authorization and coverage for lidocaine injection 10 mg and associated inpatient stay. The Health Insurer has denied this request and reported that the requested services and requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested services and requested medication in this clinical setting. A stepwise, exhaustive trial of numerous medications from different classes has been used for both migraine prophylaxis and acute abortive treatment. This patient has tried the new anti-calcitonin gene-related peptide medications, without improvement in her symptoms. She has had several inpatient admissions for infusions of different medications, including sodium valproate, dihydroergotamine, and Thorazine. She has also had multiple injections to the greater occipital nerve, without improvement in her symptoms. There are published studies supporting the use and efficacy of intravenous lidocaine in migraine and chronic daily headache. Due to the potential side effects of this medication, close monitoring in an intensive care unit is required. In sum, lidocaine injection 10 mg and associated inpatient stay are likely to be of greater benefit than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 58-year-old male enrollee has requested reimbursement for Oncotype DX Prostate Cancer Assay performed on 11/13/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer.  The physician reviewer found that the patient is a 58-year-old male with a history of elevated prostate-specific antigen level. On 10/18/17, pathology report noted prostatic adenocarcinoma, Gleason score 3+4=7. The tumor involved four of 12 cores. The patient has requested reimbursement for Oncotype DX Prostate Cancer Assay performed on 11/13/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. The medical evidence has not established the superior effectiveness of the services at issue in this clinical setting. This testing has not been validated with prospective randomized clinical trials to change outcomes and impact survival or quality of life. There is a lack of support for the use of this molecular test to determine the appropriateness of observation or active surveillance. Thus, Oncotype DX Prostate Cancer Assay performed on 11/13/17 was not likely to be 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: Upheld

Summary Reviewer 

The patient is a 16-year-old male with idiopathic short stature. He presented to his endocrinologist at the age of 8 years 6 months with height at approximately the third percentile. The physician reviewer found that the submitted documentation does not support the medical necessity of the requested medication. Based on the bone age of 13 years, the calculated predicted adult height is 187 cm or 73.6 inches. Based on the bone age of 13.5 years, the calculated predicted adult height was 182.4 cm or 71.8 inches. These are based on values per Greulich and Pyle method. The U.S. Food and Drug Administration has approved the use of growth hormone therapy for idiopathic short stature or non-growth hormone-deficient short stature defined as height standard deviation less than or equal to -2.25 or less than or equal to 1.2nd percentile for age and gender. In 2016, Pediatric Endocrine Society came out with guidelines and recommendations for growth hormone use and noted that the decision to treat idiopathic short stature should be made on case-by-case basis. The above patient had a history of short stature with height being at 1.2 percentile and poor growth velocity. He has been treated with growth hormone therapy. His predicted adult height of 71.8 to 73.6 inches is higher than the 66.5 inches of mid-parental height by a good margin. His current height is 64.8 inches and he is likely to achieve his mid-parental height. At this point, continued growth hormone therapy is not medically necessary. Therefore, Norditropin Flexpro 10 mg/1.5 mL pen injector is not medically necessary for the treatment of this patient.