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

Summary Reviewer 3 
 
A 50-year-old female enrollee has requested authorization and coverage for interstitial radiation 
source application, complex, includes supervision, handling, loading of radiation source, when 
performed. The Health Insurer has denied this request and reported that the requested service 
is investigational for the treatment of the enrollees oligoprogressive hepatic disease. The 
physician reviewer found that radioembolization has not been proven to yield superior survival 
probabilities for management of non-small cell lung cancer. In this case, the records do not 
indicate that the patient is symptomatic from her liver disease, for example, with pain secondary 
to tumor bulk, requiring palliative measures to improve quality-of-life. Furthermore, the patients 
disease has progressed outside of the liver and while treatment with radioembolization may 
provide control of the liver disease, it would not address the progressive nodal disease. In this 
case, the requested service is not likely to be more beneficial for the treatment of this patient 
than standard management of transitioning to the next-line systemic therapy, or to a clinical trial, 
as this would be a more comprehensive management approach that would address all of 
patients sites of disease. Therefore, interstitial radiation source application, complex, includes 
supervision, handling, loading of radiation source, when performed, is not likely to be more 
beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 45-year-old male enrollee has requested authorization and coverage for hybrid artificial disc replacement at L4-5 and fusion at L5-S1 (CPT codes 22558, 22851, 22585, 22845, 20930, 63090, 63091 and 77003). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The evidence based peer-reviewed literature does not support single-level artificial disc replacement in the setting of multilevel lumbar degenerative disc disease. In this case, the patient presents with low back pain radiating into the posterolateral left lower extremity to the foot. Clinical exam findings documented a normal neurologic presentation. There is imaging evidence of L4-5 and L5-S1 spondylosis, grade 1 retrolisthesis at L5-S1, Modic type 1 endplate changes, and mild bilateral neuroforaminal narrowing. A discogram was reportedly positive at L4-5 and L5-S1, but outcomes have not been found to be consistently reliable for the low back based upon recent studies (Eck, et al). In addition, a disc replacement adjacent to a fused spinal segment would represent a hybrid-type complex/construct of which there are a lack of long-term medical literature studies available. Therefore, the requested hybrid artificial disc replacement at L4-5 and a fusion at L5-S1 is not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. Based upon the information set forth above, the requested services are 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: Overturned

Summary Reviewer 2

A 62-year-old female enrollee has requested authorization and coverage for Xeljanz.A review of the record indicates that the enrollee has been diagnosed with alopecia areata. In an
undated letter, the provider reported that the enrollee has tried squaric acid, Rogaine, and
intralesional Kenalog injections.The Health Insurer indicates that the requested medication is investigational for the evaluation of
the enrolleeas medical condition. Therefore, the Health Insurer has denied coverage for the
requested medication. The physician reviewer found that Alopecia areata is an autoimmune medical condition that causes disfiguring patchy hair loss. This
patientas medical condition is severe. She has failed standard therapy with intralesional Kenalog,
squaric acid and Rogaine. Her provided has requested Xeljanz as the next most appropriate step in
therapy for her medical condition. This immunosuppressant medication is accepted medical
therapy for this autoimmune medical condition. Xeljanz is an immune-modulating therapy, which
has been approved by the U.S. Food and Drug Administration (FDA) for multiple immunemodulated
diseases, including rheumatoid arthritis, psoriatic arthritis, ulcerative colitis, and
juvenile rheumatoid arthritis. The safety and efficacy of Xeljanz in alopecia areata is welldescribed
in current literature. Since this patient has failed standard therapy, Xeljanz is the
appropriate next step in therapy. Therefore, Xeljanz is likely to be more beneficial than other
available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 30-year-old female enrollee has requested reimbursement for Prometheus Anser ADA (84999) provided on 10/14/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees inflammatory bowel disease (IBD). The physician reviewer found that it has not yet been established in the medical evidence whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established, as in this patients circumstance. The Prometheus Anser IFX test is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies, and the Anser ADA test assesses serum adalimumab (ADA) and anti-ADA antibodies. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or adalimumab or the presence of IFX or ADA antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. As such, the clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement. All told, Prometheus Anser ADA (84999) provided on 10/14/15 was not likely to have been more efficacious than other alternatives in evaluating this patients medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been 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 2

A 26-year-old female enrollee has requested reimbursement for DecisionDx testing performed on 4/28/17. 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 cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion. Metastases to regional lymph nodes may be amenable to excision but suggest an increased risk for the development of metastatic disease in the future (Balch, et al). The data on the DecisionDx test for melanoma does not support its routine use after sentinel lymph node biopsy. According to the National Comprehensive Cancer Network (NCCN), there has been a lack of consistency with various genes being used as biomarkers in this clinical setting. Thus, the DecisionDx testing performed on 4/28/17 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

A 31-year-old female enrollee has requested reimbursement for osteochondral knee autograft CPT code 27416 performed on 3/7/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee who had injured her left knee. The physician reviewer found there is evidence of the effectiveness of the osteochondral autologous transfer for patients with a single, traumatically caused grade III or IV femoral condyle deficit who are under 40 years of age and have an active lifestyle. Osteochondral autologous transfer (OAT) technique is a method used to slow down the development of osteoarthritis. In the article by Werner and colleagues, 152 OAT procedures were  reviewed, of which 20 competitive athletes met inclusion and exclusion criteria. All patients underwent an accelerated rehabilitation program after their procedure. Return to sport was determined for all athletes. All athletes were able to return to sport at their previous levels and reported that they were satisfied or very satisfied with their surgical outcome and ability to return to sport. The medical literature shows promising results of this technique at medium to long term follow up. In this patients case, she had a single full thickness articular cartilage lesion in the weight bearing zone. According to the medical literature, this patient was likely to have benefitted from this procedure when compared to other methods of therapy. Accordingly, osteochondral knee autograft, CPT code 27416 performed on 3/7/17 was likely to have been more efficacious for the treatment of this patients medical condition than any other available treatment options. Based upon the information set forth above, the services at issue were 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: Experimental
Decision: Overturned

Summary Reviewer 2

The parent of an 11-year-old female enrollee has requested authorization and coverage for gene testing.  The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition.The physician reviewer found the medical evidence supports the requested gene testing in this clinical setting.  In this patients case, her constellation of symptoms may represent atypical Gitelman syndrome or atypical Bartter syndrome.  Gitelman syndrome is an autosomal recessive genetic kidney disorder that results in imbalance of ionic substances in the body such as potassium and magnesium.  Patients may experience weakness and cramping, as well as fatigue, hypotension, and ventricular dysrhythmias.  Bartter syndrome is also an autosomal recessive genetic kidney disorder that results in imbalance of electrolytes in the body.  Patients may experience dehydration, constipation, polyuria, osteopenia, and sensorineural hearing loss.  Identification of the underlying disorder will be beneficial to this patient for future medical management.  Therefore, the requested gene testing is likely to be superior over other methods of evaluating this patient.  Based upon the information set forth above, the requested services are 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 2


A 65-year-old male enrollee has requested reimbursement for collagen crosslink testing performed on 7/11/15.  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.  The National Osteoporosis Foundation approves the use of biochemical markers of bone turnover as a tool to investigate causes of osteoporosis and then as a follow-up test to monitor response and compliance with antiresorptive therapy.  This test may be done to assess response to therapy sooner than the one- to two-year follow-up dual-energy x-ray absorptiometry (DEXA) scan study that quantifies response in bone density measurements.  In this case, the test provided information regarding the response to Prolia therapy. The significant reduction of the C-telopeptide level is consistent with excellent response to antiresorptive therapy with Prolia.  In sum, collagen crosslink testing performed on 7/11/15 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 56-year-old transgender female who has been diagnosed with gender dysphoria. The patient has requested authorization and coverage for facial feminization surgery. 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 the current medical evidence supports the requested services in this clinical setting. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, aimproved mental health-related quality of life.a The World Professional Association for Transgender Health position statement states, aNon-genital surgical proceduresanotably facial feminization surgeryaare often of greater practical significance in the patientas daily life than reconstruction of the genitalsaThese reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition.a There is sufficient support for the requested services in this patientas case. Therefore, the requested facial feminization surgery is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1
A 49-year-old female has requested authorization and coverage for 22857 [total disc 
arthroplasty (artificial disc), two-day inpatient stay]. 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
the disc arthroplasty procedure has been in use for over a decade. Current medical 
literature demonstrates that its outcomes are superior to fusion. In a randomized, 
controlled, multicenter trial, Gornet and colleagues concluded that the group 
receiving lumbar disc arthroplasty consistently demonstrated statistical superiority
versus fusion on key clinical outcomes including improved physical function, reduced
pain, and earlier return to work. In reviewing the five-year outcomes, the authors 
reported that lumbar disc arthroplasty is a safe and effective treatment. Therefore,
22857 [total disc arthroplasty (artificial disc), two-day inpatient stay] is likely 
to be more beneficial for treatment of the patient's condition than any available 
standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 40-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 9/9/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer.  The physician reviewer found that there is a lack of peer-reviewed literature that supports the use of three-dimensional breast tomosynthesis compared to currently available techniques, especially in a patient without an increased risk of breast cancer. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in peer-reviewed literature. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 9/9/16 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 service 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 parent of a four-year-old male enrollee has requested authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) therapy. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees autism spectrum disorder. The physician reviewer found the Health Insurer has authorized 25 hours per week of ABA services. Several studies recommend 25 or more hours of weekly ABA to ensure optimal outcomes (Roane et al; Myers et al). The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In this case, the patient demonstrates delays in social, cognitive, adaptive and executive functioning deficits and continues to demonstrate maladaptive behaviors of aggression, physical stereotypy and perseveration. In this clinical setting, 40 hours per week of ABA therapy is medically necessary for treatment of the patients medical condition. 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

The parent of a 12-year-old male enrollee has requested authorization and coverage for functional electrical stimulation RT300 therapy system.  The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees incomplete paraplegia. The physician reviewer found transversemyelitis is a neurological disorder caused by inflammation across both sides of one level of the spinal cord.  The inflammation can damage or destroy myelin.  Symptoms of transverse myelitis include a loss of spinal cord function.  What usually begins as a sudden onset of lower back pain, muscle weakness, or abnormal sensations in the toes and feet can rapidly progress to more severe symptoms, including paralysis, urinary retention, and loss of bowel control.  Although some patients recover from transverse myelitis with minor or no residual problems, others have permanent impairments that affect their ability to perform tasks of daily living.  Functional electrical stimulation applies small electrical pulses to paralyzed muscles to restore or improve their function.  Functional electrical stimulation is used in neurologically impaired individuals, including those with spinal cord injury and stroke, to stimulate muscles during activity.  Per the medical evidence, functional electrical stimulation can minimize contractures and can decrease spasticity.  The current medical evidence supports the requested device in this clinical setting.  In sum, the requested functional electrical stimulation RT300 therapy system is likely to be superior over other treatment alternatives.  Based upon the information set forth above, the requested device is 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: Experimental
Decision: Overturned

Summary Reviewer 1

A 64-year-old female enrollee has requested placement of permanent sacral nerve stimulator performed on 12/09/14.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees fecal incontinence. The physician reviewer found the current medical evidence supports the services at issue in this clinical setting.  There is clinical data to support the long-term efficacy and safety of the services at issue for the treatment of bowel dysfunction.  Wexner and colleagues published results of a prospective multicenter study of sacral nerve stimulation for fecal incontinence.  The authors concluded that sacral nerve stimulation using InterStim is a safe and effective treatment for patients with fecal incontinence.  Moya and colleagues reported results of 50 patients implanted with sacral nerve stimulators.  After six months, sacral nerve stimulation significantly improved fecal incontinence and positively impacted quality of life.  All told, the permanent sacral nerve stimulator provided on 12/09/14 was likely to have been superior over other treatment modalities.  Based upon the information set forth above, the services at issue were 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: Experimental
Decision: Upheld

Summary Reviewer 3


A 60-year-old male enrollee has requested reimbursement for St. Jude Nanostim Leadless Pacemaker implant provided on 6/24/15. The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition.The physician reviewer found The services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Despite the potential advantages of a leadless device, the long-term data demonstrating safety in large clinical follow-up is lacking. There have also been documented complications of the leadless device. In sum, there is a lack of data supporting the long-term safety and efficacy of the services at issue to establish the St. Jude Nanostim Leadless Pacemaker implant 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 services at issue were 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.