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

Summary Reviewer 3

A 37-year-old female enrollee has requested authorization and coverage for an implanted electrical stimulator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees pain. The physician reviewer found that the medical records fail to demonstrate the superior efficacy of the requested device. It is unclear if other standard treatment options for neck and shoulder pain have been done. General statements of undergoing all conservative treatment measures available without specific names, duration with quantities, and results, is insufficient. The medical records indicate that other treatment options have not been exhausted. There are other standard treatment options that are not invasive or permanent, that have not been documented to have been tried and failed. Finally, no mention of the completion of behavior therapy has been documented despite research to support its use. Thus, the requested implanted electrical stimulator is not likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested device 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: Experimental
Decision: Upheld

Summary Reviewer 3 
 
A 24-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 7/06/21. 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 gene expression profile (GEP) testing, such as DecisionDx-Melanoma, can  help to make a melanoma diagnosis if the lesion is indeterminate and can help identify targetable 
mutations.  Testing can also help categorize risk for disease progression, but it is unclear if tests 
such as DecisionDx-Melanoma outperform current standards, including histopathology and 
sentinel lymph node biopsy. In this case, the lesion was early stage (T1a), and GEP testing is not 
recommended  by  National  Comprehensive  Cancer  Network  guidelines  in  this  setting.  The 
medical  evidence  has  not  demonstrated  that  DecisionDx-Melanoma  testing  is  superior  to 
standard testing, and DecisionDx-Melanoma testing does not change management as wide 
excision is the only recommend therapy per the guidelines. Therefore, DecisionDx-Melanoma 
testing performed on 7/06/21 was not likely to have been more beneficial than any available 
standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 62-year-old female has requested authorization and coverage for spine nerve treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees back pain. The physician reviewer found there is a lack of support for the requested services in this clinical setting. Sufficient clinical details supporting the requested spine nerve treatment are lacking. The clinical notes are vague and specify only radicular pain. The records do not clearly establish that the patient has back pain of facet origin or referred pain from the facets. Thus, the superior efficacy of the requested spine nerve treatment has not been demonstrated in this patients case.  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: Upheld

Summary Reviewer 1

A 64-year-old female enrollee has requested reimbursement for FoundationOne test performed on 1/19/17. 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 foound that the medical studies do not support the superior efficacy of the services at issue in this clinical setting. FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. However, there is a lack of evidence that the assay adds to the decision making ability of the provider, or yields a result that is clinically beneficial. There are various non-randomized studies exploring the value of molecular profiling but these studies are not definitive or compelling as to the efficacy of the assay. A study by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular targets. As such, the FoundationOne test performed on 1/19/17 was not likely to have been more efficacious than other methods of evaluating this patients medical condition. Therefore, for the reasons stated 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: Overturned

Summary Reviewer 3

A 33-year-old female enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) test and Factor V Leiden performed on 5/17/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of deep vein thrombosis and pulmonary embolism. The physician reviewer found that the submitted documentation supports a portion of the services at issue. Factor V Leiden screening is recommended for women with a past history of deep vein thrombosis/pulmonary embolism. However, the clinically usefulness of the MTHFR mutations are unknown, and routine screening is not recommended. Given the lack of association between either heterozygosity or homozygosity for the MTHFR C677T polymorphism and negative pregnancy outcomes, MTHFR testing is not recommended. Thus, Factor V Leiden performed on 5/17/18 was likely to have been of greater benefit than other methods of evaluating this patient. However, the superior effectiveness of MTHFR testing has not been demonstrated. Based upon the information set forth above, a portion of the services 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 partially overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 34-year-old male enrollee has requested authorization and coverage for Bicillin L-A. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition.  the physician reviewer found THE requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard. The patient does not have clinically documented late stage Lyme disease either in the form of Lyme arthritis or neuroborreliosis. Tremor alone is not a finding in late stage Lyme disease. In addition, the patient does not have laboratory results documenting late stage Lyme. There is no IgG positive titer or positive cerebrospinal fluid or synovial fluid results. There is no joint effusion and no neurologic deficits documented. Moreover, the treatment of late stage Lyme disease, if established, is a four-week course of intravenous ceftriaxone. Long courses or repeat courses of antibiotic have not demonstrated efficacy in multiple trials. In sum, there is a lack of documentation supporting a diagnosis of late stage Lyme disease. Therefore, the requested medication is 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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 24-year-old female enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). 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 that the Health Insurer has denied this request as investigational indicating medical studies do not show that IMRT works as well as or better than other types of treatment. There are emerging data for the use of IMRT for Hodgkins lymphoma (Chera, et al). The rationale to use IMRT includes relative sparing of the lungs, heart, salivary glands, breast and other tissues. Reducing the mean cardiac dose is particularly clinically relevant in a patient expected to have a long term survival, particularly if cardiotoxic drugs were used, such as is in this case. Hodgkin lymphoma fields have historically been much more comprehensive in terms of volume. For this patient, clinically significant reductions in dose-volume measures with IMRT are seen in the mean heart dose; left breast, and esophageal dose exposure is also reduced with IMRT. In younger patients, IMRT is used to spare breast tissue, in order to reduce subsequent breast cancer risks. In sum, IMRT is indicated for this patient and there is sufficient support provided showing a plausible, clinically meaningful benefit in this patient. Given the support above, IMRT 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: Upheld

Summary Reviewer 1

A 57-year-old female enrollee has requested reimbursement for the gene test performed on 8/12/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the commercial gene expression profile test (DecisionDX-Melanoma) has been developed in patients with stage I and II cutaneous melanoma. However, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials according to published data available. Per the National Comprehensive Cancer Network (NCCN) guidelines, the gene expression profile test is still not recommended for routine (baseline) genetic testing of primary cutaneous melanomas.  At this time, the gene test performed on 8/12/15 was not likely to be of greater benefit than available standard therapy for the evaluation of 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: Overturned

Summary Reviewer 1

The parent of an 11-year-old female enrollee has requested reimbursement for the FirstStep PLUS test provided on 11/23/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees severe attention deficit hyperactivity disorder (ADHD) and developmental delays. The physician reviewer found that the clinical utility of CMA is well established, and is now considered first-line genetic tests for patients with developmental delays and autism spectrum disorders according to the American Academy of Pediatrics, the American College of Medical Genetics, the American College of Neurology and the Child Neurology Society (Schaefer, et al; Moeschler, et al; Shevell, et al; Shen, et al). In a study by Coulter and colleagues, a retrospective chart review of CMA testing was performed on patients with developmental delay, intellectual disability, autism spectrum disorders and congenital anomalies. Findings in this study demonstrated that CMA results influenced medical care by in the majority of patients by precipitating medical referrals, diagnostic imaging, or specific laboratory testing, supporting the use of CMA as a clinically useful diagnostic test. It is for these reasons, that the FirstStep PLUS test provided on 11/23/16 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: Experimental
Decision: Overturned

Summary Reviewer 2

A 51-year-old male enrollee has requested reimbursement for DecisionDX testing provided on 10/6/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees uveal melanoma.  The physician reviewer found uveal melanoma is a rare cancer that requires vigilant observation to detect clinical metastases early enough to undergo meaningful treatment. Uveal melanomas may be divided into two primary types, based upon gene expression. One of these types has a very low incidence of malignancy, while the other has a notably high rate. Once the type of the tumor can be determined, a clinical decision can be made as to how frequently the patient needs to undergo extensive medical surveillance and imaging for the remainder of their life. Currently, the DecisionDX has adequate support in the peer-reviewed medical literature for use in this clinical setting. Further, data suggests that the results are clinically significant and therefore important for patient care. The routine use of DecisionDX for uveal melanomas has been adopted by the vast majority of the tertiary care centers that treat this disease, thus making it the standard of care. For these reasons, the DecisionDX testing provided on 10/6/14 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, I have determined the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 20-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 8/14/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Polymerase chain reaction testing has been compared to traditional clinical testing for vaginitis. The literature supports the use of polymerase chain reaction testing because it has resulted in significantly higher sensitivity and negative predictive value than clinician diagnosis or in clinic testing. The test may also be superior for detecting more than one cause for vaginitis. The services at issue were appropriate in this patients case. Therefore, polymerase chain reaction testing performed on 8/14/18 was likely to have been more effective than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 52-year-old female enrollee has requested authorization and coverage for the LINX procedure. 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 LINX device has been approved for patients with diagnosed gastroesophageal reflux disease as defined by abnormal pH testing, and who continue to have chronic gastroesophageal reflux disease symptoms despite maximal medical therapy for the treatment of reflux.  At this time, comparative studies with other anti-reflux surgeries are needed.  In this patients case, it appears she has benefited to a significant degree from acid suppression treatment, and as such cannot be considered medically refractory to acid blocker drugs. There is also room for lifestyle modification.  All told, available records do not support that the LINX device is likely to be more beneficial for treatment of the patients medical condition than available standard therapy.  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: Upheld

Summary Reviewer 2

A 63-year-old male enrollee has requested reimbursement for the Foundation One test performed on 3/13/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees metastatic poorly differentiated carcinoma. The physician reviewer found that Foundation One testing offers a comprehensive panel of molecular genetic markers on an individual patients tumor in an attempt to identify markers than can help guide therapy decision making. Per the National Comprehensive Cancer Network (NCCN) guidelines, it has not been determined if molecular markers are useful in treatment determination and prognosis other than the tests developed for localized prostate cancer. The National Cancer Institute (NCI) is currently conducting a phase II clinical trial evaluating the efficacy of genetic molecular testing to guide individual patient therapy. As Foundation One provides genetic testing to guide therapy and this is the subject of an ongoing phase II trial its use remains investigational at this time. Accordingly the Foundation One test performed on 3/13/16 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: Experimental
Decision: Upheld

Summary Reviewer 3

A 49-year-old female enrollee has requested reimbursement for Guardant360 CDx testing performed on 3/22/21. 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 based on the records, this patient had two previous molecular assays. Thus, the services at issue were the third such assay. There is a lack of convincing data to demonstrate that in pancreatic cancer, choosing chemotherapy by molecular assay is superior to standard decision making. Although NCCN guidelines note the possible value of determining certain mutations in pancreatic cancer, there is no reason to believe that a third such assay would be of clinical benefit. As noted by Marquardt, the percentage of patients who benefit from such genome-based therapeutics appears to be quite low. Therefore, Guardant360 CDx testing performed on 3/22/21 was not likely to have been more beneficial for evaluation of the patientas condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 53-year-old female enrollee has requested reimbursement for the ColonSentry testing performed on 1/20/15. The Health Insurer has denied this request indicating that the diagnostic testing at issue is considered investigational for evaluation of the enrollees risk for colorectal cancer.  The physician reviewer found that the ColonSentry test is typically performed to help patients decide on whether or not a colonoscopy may be indicated. The ColonSentry test does not replace colonoscopy as the gold standard for colon cancer screening. In this case, the case file does not show any contraindication to colonoscopy. As such, the ColonSentry testing performed on 1/20/15 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: Upheld

Summary Reviewer 1

A 50-year-old female enrollee has requested reimbursement for CPT code 81479 (unlisted molecular pathology, Cxbladder) performed on 12/19/18. 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 there is a lack of support for the services at issue in this patients case. Cxbladder testing is not a screening test for urothelial cancer. Cystoscopy and possible biopsy and upper tract imaging will still be necessary regardless of the results of Cxbladder testing. Urinary biomarker tests such as Cxbladder give significant false-negative results in patients with bladder cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors. To date, there are multiple urine markers that have improved sensitivity over cytology, but there is lack of validation of clinical utility. Some of the recently developed markers aim to change the paradigm of urothelial diagnosis and follow-up by replacing or reducing the need of invasive investigations. Further prospective validations are needed to confirm these findings. Therefore, CPT code 81479 (unlisted molecular pathology, Cxbladder) performed on 12/19/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2
A 36-year-old male enrollee has requested reimbursement for an implantable ambulatory event monitor provided on 12/28/17. The Health Insurer has denied this request indicating that the device at issue was considered investigational for evaluation of the enrollee, who reported palpitations. The physician reviewer found that the patient is a 36-year-old male who reported palpitations. He was evaluated with a 30-day event monitor which demonstrated an episode of atrial fibrillation lasting 30 seconds. The patients provider recommended an implantable loop recorder to assist with treatment planning given the risks of bleeding if anticoagulation was initiated. The patient has requested reimbursement for an implantable ambulatory event monitor provided on 12/28/17. The Health Insurer has denied this request and reported that the device at issue was investigational for the evaluation of this patient. There is a lack of support for the device at issue in this patients case. The medical evidence does not support an implantable loop recorder for monitoring for atrial fibrillation burden in this clinical setting. The use of an implantable loop recorder is supported if the patient has had cryptogenic stroke or recurrent syncope and has had negative results of external electrocardiogram monitoring. This patient was shown to have a 30-second episode of atrial fibrillation on the initial event monitor performed. In sum, the implantable ambulatory event monitor provided on 12/28/17 was not likely to have been superior over other available methods of evaluating this patient. Based upon the information set forth above, the device 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.