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

Summary Reviewer 2


A 57-year-old female enrollee has requested reimbursement for tumor necrosis factor antagonist testing performed on 4/04/15.  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 submitted documentation fails to demonstrate the superior effectiveness of the services at issue.  The testing in dispute was ordered to determine the etiology for possible loss of response to Humira.  The use of Anser ADA has not been clinically proven in controlled studies to improve patient clinical outcomes or to be more effective than conventional courses.  Patients treated with Humira may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear.  Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. Clinical guidelines for management of inflammatory bowel disease do not recommend testing for anti-drug antibody during clinical management.  Therefore, tumor necrosis factor antagonist testing performed on 4/04/15 was not likely to have been of greater benefit than other modalities for 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 3

A 63-year-old male enrollee has requested authorization and coverage for surgical insertion of an interspinous process spacer. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient had a long history of neurogenic claudication. He has failed conservative treatment for over six months, including nonsteroidal anti-inflammatory drugs, opioids, physical therapy, epidural steroid injections, and bracing. His provider has recommended minimally invasive interspinous process spacer using the Superion device. Nunley and colleagues presented a four-year follow-up of 89 patients who underwent the procedure for spinal stenosis. At four years after the procedure, 75 of 89 patients with Superion (84.3%) demonstrated clinical success in terms of back and leg pain. The minimally invasive implantation procedure of the Superion device provided relief of symptoms of intermittent neurogenic claudication in these patients with moderate lumbar spinal stenosis. The second article referenced is a five-year follow-up and indicated that 75 percent of these patients continued to do well and did not require any other treatment such as an open decompression/fusion procedure. Thus, the requested surgical insertion of an interspinous process spacer is likely to be more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a 10-year-old male enrollee has requested authorization and coverage for Omnitrope (somatropin) injection 1.3 mg/day, six days per week. 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 no evidence of poor growth on the growth chart. In fact, he went from the 5th to 10th percentile. The diagnosis of growth hormone deficiency without clinical evidence of poor linear growth cannot be supported. Accordingly to guidelines, there is not a single test to diagnose growth hormone deficiency. Although this patient failed the growth hormone stimulation test, in the absence of poor growth, this test alone cannot establish the diagnosis of growth hormone deficiency. This patient was pre-pubertal at 10 years of age. It is likely his growth rate will increase even more when he enters puberty. There is a lack of support for the requested medication in this clinical setting. Therefore, Omnitrope (somatropin) injection 1.3 mg per day, six days per week is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 30-year-old female enrollee has requested reimbursement for bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient presented with a longstanding history of bilateral severe hallux valgus deformity, left greater than right. She complained of pain with weight-bearing. Conservative treatment had included activity modification, bracing, wide shoes, and nonsteroidal anti-inflammatory drugs. She had a left hallux valgus angle (HVA) of 35 degrees, and intermetatarsal angle (IMA) of 15 degrees. She had a right HVA of 35 degrees, and intermetatarsal angle (IMA) of 18 degrees. She underwent left chevron osteotomy and modified McBride procedure with x-ray fluoroscopy on 6/10/19, and right scarf osteotomy and modified McBride procedure with x-ray fluoroscopy on 7/29/19. Current evidence-based medical literature supports the use of surgical treatment of hallux valgus in this clinical setting, given the severity of the HVA and IMR angles, significant pain and functional impairment, and failure of non-operative treatment. Additionally, there is no indication in the literature to support ongoing conservative treatment over surgical correction in the setting of severe deformity. Therefore, bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19 was likely to have been more beneficial than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3
A 19-year-old female enrollee has requested reimbursement for electromyography (EMG) and electroencephalogram (EEG) monitoring during spine surgery performed on 12/05/19. 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 in spinal deformity corrective operations, the use of intraoperative neurophysiologic monitoring has become standard of the care. The medical literature has shown the beneficial effects of this type of intraoperative monitoring. This type of monitoring has been helpful in avoiding potential catastrophic neurologic injury and allows the surgeons to be vigilant and to be able to reverse neurophysiological changes. This modality may prevent catastrophic permanent neurologic injury. Therefore, EMG and EEG monitoring during spine surgery performed on 12/05/19 was likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 59-year-old female enrollee has requested reimbursement for Foundation One CDX testing performed on 11/23/18. 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 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, but is not yet ready for routine clinical use. Although the ability to decipher genomic aberrations in individual breast cancers to the single nucleotide resolution is now possible, there is a lack of data to show that this information can guide treatment decisions for patients with metastatic breast cancer. The use of next generation sequencing, such as with FoundationOne CDx testing, continues to be the subject of ongoing clinical trials. Therefore, FoundationOne CDx performed on 11/23/18 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 47-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/06/16.  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 there is sufficient support for the service 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 integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  In sum, the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  Therefore, digital breast tomosynthesis performed on 7/06/16 was likely to have been of greater benefit than other modalities for 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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 53-year-old female enrollee has requested authorization and coverage for vascularized lymph node transfer (VLNT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the patient has a long history of lower extremity lymphedema secondary to treatment for cervical cancer. The patients therapy has consisted of compression devices and a short term of decongestive therapy. This has had significant functional effect on her life as she has been unable to resume her normal physical activity and has had six episodes of lower extremity cellulitis. Vascularized lymph node transfer has demonstrated significant benefit in multiple case series to reduce the extent of lymphedema and increase quality of life. While there is a lack of prospective comparison trials, the results of the multiple single center case series are compelling and are sufficient to demonstrate an anticipated benefit for this patient. Therefore, the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a 17-year-old female enrollee has requested reimbursement for residential mental health treatment for children and adolescents provided from 10/24/18 through discharge. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2. The medical records indicate that the patient was not actively suicidal. The progress notes indicate that the patient was not engaging in self-harm behaviors or expressing suicidal ideation. She did have a history of suicidal ideation. With regards to functional status, the records support a score of 2. The patient had some issues with level of function, but the progress notes indicate significant improvement after a period of deterioration as evidenced by appropriate activities of daily living and grooming as well as therapy participation. In terms of comorbidity, the records support a score of 2. The patient did not have active medical problems, and she reported a history substance use with several substances. She did not describe continued cravings, and there was no documentation of withdrawal symptoms. With regards to level of stress of the recovery environment, the records support a score of 2. The patient was noted to have interpersonal conflict with the family as a focus of treatment. However, the progress notes document that her family therapy sessions were productive and not adversarial. In terms of level of support of the recovery environment, the records support a score of 2. The patients mother was involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 3. The patient had a good response to a short period in the residential treatment center prior to the disputed dates. Her presentation during the disputed timeframe indicates that she was cooperative in treatment. In terms of acceptance and engagement of the patient, the records support a score of 2. The patient actively participated in therapy, and she was able to develop a positive relationship with clinicians. With regards to acceptance and engagement of the parent, the records support a score of 2. The patients parent worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 17. This score correlates with intensive outpatient services. Therefore, residential mental health treatment for children and adolescents provided from 10/24/18 through 11/02/18 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 58-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing provided on 4/24/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. DecisionDx-Melanoma Gene Assay assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class 1 consistent with a low risk of metastasis or Class 2 suggestive of a high risk of metastasis. According to the results of analysis of this patients DecisionDx-Melanoma Gene Assay testing, the tumor was classified as Class 2A with molecular signature associated with a high risk of near term (within five years) metastatic disease, such as 77% recurrence and 80% distant metastasis free rates. Identification of the increased risk of recurrence of melanoma in this patient helped establishing appropriate follow up plan to improve the outcome in this particular patient. Thus, the DecisionDx-Melanoma Gene Assay testing provided on 4/24/17 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 46-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 1a. The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. This recommendation is based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. In this case, the patient has hepatitis C without evidence of cirrhosis on liver biopsy in 2011 or ultrasound in 2015. Although FibroScan in 2015 was consistent with cirrhosis, the patients aspartate-to-platelet ratio index (APRI) based labs on that date were not consistent with advanced fibrosis or cirrhosis. Therefore, the 12 week therapy recommendation should apply, rather than the 24 week duration recommended for patients with cirrhosis. Thus, a 12 week course of Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus. In conclusion, 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 3


A 63-year-old male enrollee has requested authorization and coverage for transcatheter radiofrequency ablation. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees paroxysmal atrial fibrillation.  The physician reviewer found the guidelines from the Heart Rhythm Society give a Class I recommendation for ablation if the patient has failed at least one Type I or Type III anti-arrhythmic medication. This patients records do not document that he has been treated with a medication that meets these criteria. Trial of such medication might require use of a permanent pacemaker or close electrocardiography monitoring while on a medication trial to see if the patients bradycardia is worsened. The guidelines also state that a patient with a high congestive heart failure, hypertension, age, diabetes mellitus, and prior stroke (CHADS) score would need to stay on long-term anti-coagulants for stroke prevention even after successful ablation. All told, this patient has not met the established criteria for medication trial, and thus the requested transcatheter radiofrequency ablation is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested service 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 58-year-old female who was evaluated in the emergency department on 12/22/19. The patient has requested reimbursement for emergency room physician services provided on 12/22/19. The Health Insurer has denied this request and reported that the services at issue were not required on an emergent basis. The physician reviewer found that at issue in this case is whether a prudent layperson in the patientas circumstances would believe he or she was experiencing an emergency medical condition. California law defines an aemergency medical conditiona as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patientas health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. This patient presented with the sudden onset of low back pain. There was no recent trauma, and the patient did not have a history of low back pain. She had tried over-the-counter pain medication, without relief. Her symptoms continued to worsen over the course of the next day. The patientas lumbar CT scan and MRI revealed multilevel degenerative changes. Despite intravenous pain medication, the patient was still unable to ambulate and was unable to be discharged. The sudden onset of severe low back pain that does not respond to over-the-counter pain medication with the inability to ambulate meets prudent layperson criteria for an emergency. A prudent layperson in these circumstances would reasonably expect the absence of emergency care to jeopardize her health. Therefore, this patientas symptoms on 12/22/19 met prudent layperson criteria for emergency care.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 57-year-old female enrollee has requested reimbursement for testing for cancer risk using panels of genes (MyRisk) provided on 6/05/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patients family history is suggestive of a breast/ovarian cancer syndrome. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gallbladder, bile duct, prostate, pancreatic, and gastric cancers. In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. There are guidelines in place that evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer tumors in families. The most common extracolonic cancer in Lynch syndrome is endometrial cancer followed, in no particular order, by ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral. The MyRisk panel is appropriate since the current clinical situation may be caused by several potential cancer-causing genes. Thus, testing for cancer risk using panels of genes (MyRisk) provided on 6/05/19 was likely to have been more beneficial than other methods of evaluating this patient.