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

Summary Reviewer 1

A 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma assay performed on 4/12/18. 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 current medical evidence has not established the superior efficacy of the services at issue. The prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add to these statistics. DecisionDx-Melanoma assay is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami and colleagues reported on 217 cases with good correlation between prognosis and DecisionDx-Melanoma assay classification, in patients undergoing sentinel node biopsy. It is not clear how the five-year DecisionDx-Melanoma assay data compares to the ten-year Balch data. Most importantly, it is not clear if DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, DecisionDx-Melanoma assay performed on 4/12/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 63-year-old male enrollee has requested authorization and coverage for spine surgery. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees back pain. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. A review of the literature indicates evidence of good outcomes from decompression and lumbar fusions for chronic pain with or without instability, spinal stenosis and spondylolisthesis. In this case, in the presence of severe spinal stenosis and severe neural foraminal stenosis at L3-4, a wide decompression is needed. This will necessitate removal of hypertrophic facets which will lead to iatrogenic instability, necessitating a fusion procedure for stabilization. Spondylolisthesis is a known cause of instability which makes the fusion even more necessary. All told, the requested spine surgery is medically necessary for the treatment of this patient. Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 48-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 1/26/16.  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 that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  However, in this patients case, there were no problems to be resolved.  The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications.  In this clinical setting, a routine mammogram would have been sufficient.  Breast tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to multiple prior mammograms.  Therefore, breast tomosynthesis performed on 1/26/16 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 63-year-old female 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 hepatitis C virus. The physician reviewer found 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 should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). In addition, FibroSure has demonstrated high specificity when predicting advanced fibrosis, as in this case, although guidelines do not recommend restricting treatment based on fibrosis (Shaheen, et al). AASLD guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this patients hepatitis C infection. For the reasons provided, 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 52-year-old female enrollee has requested reimbursement for colorectal cancer screening; stool-based DNA and fecal occult hemoglobin performed on 9/16/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the stool-based DNA and fecal occult hemoglobin performed on 9/16/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Cologuard test analyzes stool DNA, amplifies DNA for mutational testing, and tests for stool hemoglobin. The test showed 92.3% sensitivity for colonoscopy-confirmed cancer (Imperiale, et al). In addition, these data induced the U.S. Food and Drug Administration (FDA) to approve the test for use (Patman). In this clinical setting, Cologuard 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 45-year-old male who has requested reimbursement for procedure code 81599 performed on 7/06/20. Pathology from a shave biopsy of the left lateral temple on 6/11/20 showed a malignant melanoma, Breslow depth at least 3.8 mm, with ulceration present. On 7/06/20, DecisionDx-Melanoma testing was performed. The Health Insurer has denied reimbursement for the services at issue. Per the Health Insurer, procedure code 81599 performed on 7/06/20 was not medically necessary for the evaluation of this patient.  The physician reviewer found that prognostic gene expression profiling (GEP) testing to differentiate melanomas at low versus high risk for metastasis should not replace pathologic staging procedures. Moreover, since there is a low probability of metastasis in stage I melanoma and a higher proportion of false-positive result, GEP testing should not guide clinical decision making in this group. It remains unclear where these GEP platforms provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariate nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. It remains unclear whether this GEP profile is reliably predictive of outcomes across the risk spectrum of melanoma. Prospective validation studies are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Use of this testing is not recommended by the National Comprehensive Cancer Network guidelines. Therefore, procedure code 81599 performed on 7/06/20 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 48-year-old female enrollee has requested reimbursement for Oncotype DX Colon Cancer Assay performed on 4/28/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found this patient had stage II colon cancer. Although Oncotype DX Colon Cancer Assay provides prognostic data, to date it does not provide predictive data for the benefit of chemotherapy.  Per the medical evidence, the clinical utility of gene expression assays, including the 12-gene recurrence score, is uncertain, and information is lacking regarding the extent to which assay results do or do not classify patients into distinct groups with clinical relevance.  National Comprehensive Cancer Network guidelines state that there are insufficient data to recommend the use of multigene assays, such as the Oncotype DX Colon Cancer Assay, to determine adjuvant therapy.  In sum, Oncotype DX Colon Cancer Assay performed on 4/28/16 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: Experimental
Decision: Upheld

Summary Reviewer 1

A 30-year-old female enrollee has requested authorization and coverage for Adderall XR 90 mg daily. The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). The physician reviewer found there is a paucity of scientific literature supporting a dose of Adderall XR above 60 mg. Doses above 60 mg have not been demonstrated to be more effective than lower and safer doses of Adderall. There are also cardiovascular concerns with doses above 60 mg. There is no substantial evidence suggesting that 90 mg of Adderall XR is more efficacious than 60 mg. There is also concern for abuse potential with doses higher than recommended as tolerance, psychological dependence, and social disability can occur if taken at higher than recommended doses. Given these findings, the requested Adderall XR 90 mg daily 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 medication dosage 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 63-year-old female with Crohns disease.  She is noted to have joint pain, and has failed Cimzia and methotrexate.  Per the provider note dated 1/24/17, she was noted to have Crohns disease flares and sharp abdominal pain since stopping Cimzia.  She was also noted to have ongoing chronic joint pain. The patient has requested authorization and coverage for Stelara injections for the treatment of Crohns disease.  The Health Insurer has denied the request as not medically necessary. Per the Health Insurer, there is no documentation that Stelara will not be used concomitantly with other biologic disease modifying antirheumatic drugs.  This denial is the subject of this appeal and determination. The current medical literature supports the use of Stelara in this patients case. A large randomized controlled trial by Sandborn and colleagues demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy, as in this patients case.  Kopylov and colleagues showed a 73% response in patients with anti-TNF-resistant Crohns disease. A significant majority of these patients were able to discontinue steroids. Stelara is more appropriate than immunosuppressants and corticosteroids in this patients case. The American College of Gastroenterology guidelines for induction of remission of Crohns disease state that immunosuppressants may not induce remission in adults with active Crohns disease with use up to 17 weeks; therefore, they are not recommended. For maintenance of remission, immunosuppressants (such as azathioprine, 6-mercaptopurine, and methotrexate) are given a weak recommendation. Corticosteroids are not an appropriate long-term primary therapy for Crohns disease.  Cimzia and methotrexate have been discontinued.  For these reasons, the requested Stelara injections are 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: Upheld

Summary Reviewer 1

A 45-year-old female enrollee has requested reimbursement for the Decision Dx melanoma test performed on 4/4/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma. The physician reviewer found 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 insufficient support in the peer-reviewed literature for the testing at issue in this clinical setting. According to the results of analysis of patients melanoma performed with Decision Dx melanoma, the tumor was classified as Class 1 with a low risk of near-term (within five years) metastatic disease. Although Decision Dx melanoma may be an independent predictor of metastasis risk, there is a lack of peer-reviewed published studies confirming this hypothesis. Therefore, Decision Dx melanoma test performed on 4/4/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 59-year-old female with a history of severe osteoporosis. The patient has requested authorization and coverage for Forteo. The physician reviewer found that osteoporosis is a growing public health problem. Once considered an inevitable consequence of aging, it is now eminently preventable and treatable. Multiple agents are currently available for treatment of this condition. Forteo (teriparatide) is of particular importance as it modulates the bone architecture acting on bone formation, rather than being an anti-resorptive agent like most of the other medications. Recent studies have demonstrated the ability of Forteo to reduce the likelihood of occurrence of vertebral and non-vertebral fractures in osteoporosis patients. The current medical evidence supports the requested medication in this clinical setting. Therefore, Forteo is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 63-year-old female enrollee has requested authorization and coverage for Harvoni for 12 weeks or Harvoni for eight weeks in the alternative. 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. In addition, treatment naive patients are recommended to be treated with Harvoni for 12 weeks. These recommendations are 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. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for treatment of this patients hepatitis C virus infection. In conclusion, 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: Overturned

Summary Reviewer 


A 26-year-old female enrollee has requested authorization and coverage for breast reconstruction. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees bilateral tuberous breast deformity. The physician reviewer found the submitted documentation establishes the medical necessity of the requested procedure. The patient presents with well-documented tuberous breast deformity and she has had previous reconstructive surgery with implants. Essentially, this has failed and the patients current condition is consistent with continued lack of breast development and findings consistent with significant breast deformity.  Based on the documentation and review of the photographs, this is not a normal variant. Significant breast deformity can exist with tuberous breasts (DeLuca-Pytell, et al; Mandrekas, et al). According to DeLuca-Pytell and colleagues, Tuberous breast deformity is characterized by an aberration of breast shape. Characteristics include a constricted breast base, hypoplastic breast tissue, herniated nipple-areola complex, deficient skin envelope inferiorly, and elevated inframammary fold. This classification is consistent with the presentation of this patient. Based on the overall clinical picture presented supported by photographs, and the fact that the patient has failed previous breast reconstruction and continues to have findings of a bilateral tuberous breast deformity, the requested procedure is medically necessary. This patient has abnormal breast development and surgical intervention is medically necessary to approximate a more normal condition. For the reasons provided, the requested procedure is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer

The patient is a 19-year-old female with cannabis use disorder, opioid use disorder, unspecified anxiety disorder and unspecified depressive disorder. She had presented with impaired functioning including school truancy and alienation/withdrawal socially. She was unable to maintain sobriety and was reported to make dangerous decisions. Outpatient treatment had failed and her providers recommended treatment in a residential recovery program. The patient has requested reimbursement for mental health residential treatment services provided from 1/20/17 through 4/19/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. The American Psychiatric Association (APA) treatment guidelines state that residential treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use. In addition, Handwerk and colleagues found that residential treatment has been shown to be particularly effective in reducing adolescent girls feelings of hopelessness, negative self-evaluation, and suicidal ideation. The records document that this patient needed residential treatment as demonstrated by her inability to maintain sobriety and functioning using outpatient modalities. Residential treatment was in accordance with generally accepted standards of medical practice and the APA guidelines. All told, the mental health residential treatment services provided from 1/20/17 through 4/19/17 were medically necessary for treatment of this patients medical condition.  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: Experimental
Decision: Upheld

Summary Reviewer 1

The patient is a 39-year-old male with biopsy proven idiopathic membranous nephropathy. Rituximab effected an improvement in proteinuria/nephrotic syndrome. However, the patients proteinuria has worsened and obinutuzumab (Gazyva) has been recommended as a second-line therapy. The patient has requested authorization and coverage for Gazyva injections. The Health Insurer has denied this request indicating that the requested medication is considered investigational. This patients records do not document that standard therapies including prednisone, cyclophosphamide, mycophenolate and cyclosporine have been tried and failed, or that the patient has a contraindication to these medications. Moreover, there is no indication in the medical literature that Gazyva is safe and effective for treatment of idiopathic membranous nephropathy. For these reasons, the requested obinutuzumab (Gazyva) injections are not 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 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.