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

Summary Reviewer 1

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 available treatment options for alopecia areata (AA) are limited. This is especially true for diffuse
involvement, where standard therapies such as topical steroids, intralesional kenalog, contact
immunotherapy and conventional immunosuppressants (systemic steroids, methotrexate and
cyclosporine) are more often than not less than satisfactory and associated with side effects.
Although there is no significant data yet from randomized clinical trials (which are currently
underway), there is substantial clinical evidence to support the use of oral JAK kinase inhibitors
such as tofacitinib for alopecia areata. In an open label pilot study by Jabbari and colleagues, eight
out of 12 patients demonstrated greater than 50% hair regrowth as measured by Severity in
Alopecia Tool (SALT) scoring. Liu and colleagues performed a retrospective study which
consisted of patients age 18 years or older with AA with at least 40% scalp hair loss treated with
tofacitinib. The authors found that 77% achieved a clinical response, and 58% of patients had a
greater than 50% change in SALT score. There have been minimal adverse effects reported to date.
Moreover, these results are better than what has been reported for contact immunotherapy and
systemic steroids. Therefore, Xeljanz is likely to be more beneficial than other available standard
therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary  
The patient is a 34-year-old male. X-rays of the lumbar spine dated 4/22/22 reported findings of 
mild upper lumbar scoliosis centered at L2 and convex to the left, with otherwise normal alignment 
and no malalignment provoked by flexion or extension. The patient has requested authorization 
and coverage for single-level lumbar fusion. The Health Insurer has denied this request and 
reported that the requested service is not medically necessary for the treatment of this patient. This 
denial is the subject of this appeal and determination. The physician reviewer found that the 
submitted documentation does not support the medical necessity of the requested service. Bydon 
and colleagues note, A trial of conservative therapy may be considered for patients with low-
grade spondylolisthesis presenting with radiculopathy and/or pseudoclaudication. These options 
may include physical therapy, epidural steroid injection, and pain medications. If unresolved, 
surgical options may include decompression alone or decompression and fusion. Chan and 
colleagues report, Patients with symptomatic lumbar spondylolisthesis may first be treated with 
conservative management strategies including, but not limited to, non-narcotic and narcotic pain 
medications, epidural steroid injections, transforaminal injections, and physical therapy. For well-
selected  patients  who  fail  conservative  management  strategies,  surgical  management  is 
appropriate. Resnick and colleagues explain, As a result of the decompression, the inherent 
instability associated with the spondylolisthesis may progress and lead to further misalignment 
that results in pain or recurrence of neurological complaints. Under these circumstances, lumbar 
fusion is considered appropriate to stabilize the spine and prevent delayed deterioration. In this 
case,  the  patient  is  a  34-year-old  male  with  back  pain,  lumbar  radiculopathy,  and  lumbar 
spondylosis. The patient reported ongoing low back pain that is interfering with his ability to return 
to work that he rated at a five as of 2/24/23. An examination revealed moderate tenderness to 
palpation over the lumbar spine. The records noted that the patient was neurologically intact. 
However, the submitted records did not include detailed documentation regarding a trial and 
failure  of  recent,  reasonable,  comprehensive,  less  invasive  conservative  care  measures,  as 
recommended prior to surgery in current medical literature. Dynamic flexion/extension films did 
not corroborate instability at the requested surgical level of L5-S1, and there was no detailed 
documentation regarding potential impending/inevitable temporary intra-operative instability. 
Therefore, single-level lumbar fusion is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 32-year-old male enrollee has requested reimbursement for gene testing (DecisionDx-Melanoma testing) performed on 1/23/19. 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 patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines indicate that 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. Newer prognostic molecular techniques should not replace standard staging procedures.  In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. 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. In sum, gene testing (DecisionDx-Melanoma testing) performed on 1/23/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3 
 
A 72-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene 
expression profile assay performed on 8/30/19. 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 Melanoma is a cancer that is curable in its 
earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling 
of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to 
regional lymph nodes may be amenable to excision, but this suggests a high risk for the 
development of metastatic disease in the future. Such patients may be observed or treated 
with interferon-alpha. The data on the DecisionDx-Melanoma gene expression profile assay has 
not made it part of routine analysis after sentinel lymph node biopsy. There has also been some 
lack of consistency between various genes being used as biomarkers. As such, the test is novel, 
and it is unclear how best to incorporate it into the treatment algorithm beyond standard 
staging techniques. Therefore, DecisionDx-Melanoma gene expression profile assay performed 
on 8/30/19 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The patient is a 30-year-old male who presented to his provider on 9/20/22. The patient has 
requested authorization and coverage for pantoprazole sodium tablet DR 20 mg twice daily. The 
physician reviewer found that the submitted documentation does not support the medical 
necessity of the requested medication regimen. There is a lack of well-designed, randomized 
controlled trials supporting the requested dosing frequency as safe and effective for treatment 
of  this  patients  condition.  In  this  case,  the  records  do  not  indicate  that  the  patient  has 
gastrointestinal bleeding of the esophagus, ulcerogenic disease, stricture, narrowing of the 
esophagus, or Barrett's esophagus that may warrant such dosing. While a Prior Authorization 
Request  Form  for  Prescription  Drugs  reported  that  the  patient  had  tried  treatment  with 
omeprazole, it does not appear that the patient has tried and failed other proton pump inhibitors 
such as lansoprazole, rabeprazole, and dexlansoprazole within the respective class and at dosing 
frequencies approved by the U.S. Food and Drug Administration (FDA). Therefore, pantoprazole 
sodium tablet DR 20 mg twice daily is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 60-year-old female with a history of progressively worsening left-sided low back pain radiating to the left buttock and down the left anterolateral thigh associated with paresthesias in the thigh. The patient has requested coverage for left side injections. 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 lumbar epidural steroid injections under fluoroscopic guidance are commonly used for treatment of low back and lower extremity radicular pain. As noted in the articles referenced here, these procedures are safe and effective. The commonly used approaches for the epidural steroid injections include the interlaminar and transforaminal. These lumbar epidural injections have been used extensively to treat radicular pain and paresthesias, as in this case. Among interlaminar and transforaminal, the transforaminal epidural injections are more widely used for treatment of lumbar and lower extremity pain. The potential advantages of transforaminal over interlaminar include more targeted delivery of the injectate steroid to the site of the nerve root compressive pathology, thereby reducing the swelling, inflammation, and nerve root compression with associated pain relief. Facet joint injections are also useful in cases of facetogenic pain, although not for radicular pain. If the provider feels the necessity to use both, in light of the degenerative changes noted on x-rays, facet injections should also be useful. Therefore, the requested left side injections are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 38-year-old female enrollee has requested reimbursement for oral device/appliance provided on 11/27/17. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollee, who has been diagnosed with sleep disordered breathing, periodic limb movement disorder, and insomnia with sleep apnea. The physician reviewer found that the submitted documentation supports the medical necessity of the device at issue. The patient was noted to have a diagnosis of obstructive sleep apnea. She opted for an oral appliance as a first-line therapy for her condition. The published joint practice guidelines of the American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM) noted we recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy.  Okuno and colleagues performed a systematic review and meta-analysis of five studies assessing the effectiveness of an oral appliance for the treatment of obstructive sleep apnea.  The authors found that an oral appliance decreased the apnea-hypopnea index as compared with a sham device. In this setting, given that a diagnosis of obstructive sleep apnea has been established, the use of an oral appliance was medically appropriate. Thus, the oral device/appliance provided on 11/27/17 was medically necessary for the treatment of this patient. Therefore, the device at issue was 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 46-year-old female enrollee has requested authorization and coverage for fentanyl citrate lozenge on a handle 200 mcg. 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 in this case, the patient has chronic pain involving several areas, which is complicated by hereditary angioedema, a life-threatening condition that can be precipitated by triggers, including pain. The patient has multiple drug allergies to several opioid medications, which range in severity from hives to life-threatening anaphylaxis. Per the submitted documentation, she has been stable on her current regiment of fentanyl lozenges and patches without further episodes of angioedema or hospitalizations. Her provider has indicated that adequate pain control is an important component to managing her hereditary angioedema. The patient has not demonstrated any irregular behavior and has been functional with the high-dose opioid therapy. There is sufficient support for the requested medication in this clinical setting. Therefore, fentanyl citrate lozenge on a handle 200 mcg is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


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 according to the documentation submitted for review, the patient has a diagnosis of chronic left lower extremity lymphedema that severely affects her function with ambulation and activities of daily living. Her condition is noted to have been partially corrected with suction-assisted lipectomy, but she still had significant lymphedema of the lower part of her leg. She continued with prescribed non-operative management of compression therapy, which has not controlled her condition. Thus, standard recommended therapy has been exhausted and has not been successful. VLNT is a well-recognized form of treatment for lymphedema that has failed conservative management. According to Cheng and colleagues (2013) Vascularized groin lymph node flap transfer using the wrist or elbow as a recipient site is an efficacious approach to treating postmastectomy upper limb lymphedema. Additional peer-reviewed references as cited above document the use of vascularized lymph node transfer as a surgical procedure that is appropriate for the treatment of lymphedema and has a reasonable chance in improving the patients condition. In addition, VLNT is consistent with standards of good medical practice after failure of conservative management which has been well-documented in this case. In addition, there is no evidence that VLNT is being performed for personal comfort or convenience. Given the above, VLNT 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: Experimental
Decision: Overturned

Summary Reviewer 3


A 62-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/02/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found 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.  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.  A routine mammogram would have been sufficient in this clinical setting.  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.  Thus, digital breast tomosynthesis performed on 8/02/16 was not likely to have been superior over other methods of evaluating this patient.  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: Experimental
Decision: Overturned

Summary Reviewer 3


A 48-year-old female enrollee has requested reimbursement for a breast tomosynthesis that was performed on 11/25/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for purposes of the enrollees breast cancer screening. The physician reviewer found 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 (Helvie). In this particular patient, she has dense breasts. While one could make the argument that her mammogram has not changed since the prior studies, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In this clinical setting, where the patient presents with dense breast tissues, the tomosynthesis was likely to be more beneficial as a screening tool than standard modalities including breast sonography. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 30-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 6/16/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the Prometheus Anser ADA test is a quantitative measurement of serum adalimumab and anti-ADA antibodies. There are few well controlled clinical trials to confirm that use of the Anser ADA test leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al). Moreover, it has not been established 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, such as in this case. For the reasons provided, the Prometheus Anser ADA diagnostic testing performed on 6/16/14 was not more beneficial for treatment of the patients medical condition than conventional treatment strategies. Based upon the information set forth above, the testing at issue was 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 3

A 25-year-old male enrollee has requested reimbursement for corneal crosslinking provided on 8/06/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the patient was diagnosed with keratoconus in April 2013.  On 5/13/14, his best corrected visual acuity was 20/40 in both eyes with manifest refraction. Corneal cross-linking has been approved by the U.S. Food and Drug Administration for keratoconus and post-refractive ectasia. The primary purpose of cross-linking is to halt the progression of corneal thinning and stiffen the cornea. Prior to this treatment, patients with keratoconus who failed medical treatment (glasses and contact lenses) and whose disease continued to progress would undergo surgical management with corneal transplantation. Although better designed randomized control trials and long-term data are still underway, there is mounting evidence of the benefit of this treatment in younger patients with keratoconus and evidence of disease progression. In this case, the records do not clearly document that this patient has evidence of progressive keratoconus as indicated by increasing keratometry values, change in best corrected visual acuity, contact lens intolerance, and corneal pachymetry measurements. Therefore, the superior efficacy of the services at issue has not been established. Thus, corneal cross-linking provided on 8/06/18 was not likely to have been more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 32-year-old female enrollee has requested authorization and coverage for Gamunex-C. 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 there is support for the requested medication in this patients case. The patient has been diagnosed with autoimmune small fiber neuropathy. As noted by Schofield and Chemali, Intravenous immunoglobulin therapy is U.S. Food and Drug Administration (FDA) approved for the immune-mediated peripheral nerve disorders Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. Immunoglobulin therapy has been used increasingly with significant efficacy in the treatment of patients with disabling autoimmune forms of dysautonomia, which are most often small fiber (autonomic and/or sensory) polyneuropathies. Intravenous immunoglobulin is used to treat a variety of autoimmune disorders, with a very good success rate. Thus, Gamunex-C is likely to be more beneficial than other available treatment options.