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

Summary Reviewer 2


A 52-year-old female enrollee has requested reimbursement for the Decision Dx melanoma assay provided on 11/18/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found that the Decision Dx melanoma assay was developed using gene signatures from ocular melanoma and associating a particular risk of future metastatic disease based on the genetic expression patterns displayed in the tumor. The Decision Dx assay is not considered within the standard of care. The National Comprehensive Cancer Network (NCCN) guidelines for the treatment of melanoma state that the Decision Dx assay should not be used outside of a clinical trial setting. As the testing is not considered to be standard of care and not recommended in the work-up of melanoma patients according to the NCCN, the Decision Dx melanoma assay performed on 11/18/15 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

The parent of a 17-year-old male enrollee has requested reimbursement for wilderness therapy program provided from 7/11/16 through 9/21/16 and from 11/3/16 through 12/27/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees behavioral health condition. The physician reviewer found that in the literature, there is lack of evidence supporting the superior treatment of wilderness therapy when compared to standard accepted therapies. In the article by Bettmann and colleagues, they reported that wilderness therapy research is significantly lacking in controlled studies. In another article by Widmer and colleagues, they noted that while some studies report benefits of wilderness therapy, caution should be exercised in the interpretation of these results. There are not enough studies that support wilderness therapy as likely to be more beneficial for treatment of the patients behavioral health condition than standard evidence based therapies. Therefore, the wilderness therapy program provided from 7/11/16 through 9/21/16 and from 11/3/16 through 12/27/16 was not likely to be have been more effective for treatment of the patients medical condition than the available standard therapies. 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.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has been thought to add a bit to these statistics. DecisionDx-Melanoma testing 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. Berger reported on 156 cases, but there was insufficient follow-up to determine the real value of the test. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear if the DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, 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: Overturned

Summary Reviewer 1

A 21-year-old male enrollee has requested reimbursement for corneal collagen crosslinking performed on 3/13/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees keratoconus. The physician reviewer found that The U.S. Food and Drug Administration (FDA) has approved this procedure. The primary purpose of crosslinking is to halt the progression of corneal thinning that occurs with conditions such as keratoconus. The procedure involves soaking the corneal stroma with riboflavin and then using ultraviolet light to create chemical bonds between collagen fibrils within the stroma. This stiffens the cornea and halts the thinning. Prior to this treatment, patients with keratoconus who failed medical treatment and whose disease continued to progress would undergo surgical management with corneal transplantation. Although this patient has been diagnosed with keratoconus, there is a lack of evidence that there has been progression of disease to warrant a crosslinking treatment. Examination notes indicate excellent visual acuity and minimal refractive error in the right eye.  In addition, there is a lack of anterior segment examination detail, keratometry, and corneal topography that would confirm the disease and its progressive nature. Therefore, corneal collagen crosslinking performed on 3/13/17 was not likely to have been of greater benefit than other treatment options. 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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 79-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that based on the current evidence, the Watchman device is non-inferior to systemic anticoagulation treatment for long-term stroke prevention due to paroxysmal or persistent atrial fibrillation. This has been demonstrated in both the PROTECT AF trial and the PREVAIL trial. Given the patientas elevated stroke risk and his unsuitability for long-term anticoagulation to his occupational risk of head trauma, he is an acceptable candidate for a Watchman device. Therefore, percutaneous transcatheter closure of the left atrial appendage with endocardial implant is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2
A 53-year-old female enrollee has requested reimbursement for collagen cross links testing performed on 11/17/15. 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 fragility fracture.The physician reviewer found that the evidenced based peer reviewed medical literature does not recommend collagen cross links laboratory testing for the management of osteoporosis. The available literature is inconclusive as to its efficacy and usefulness in this clinical setting. The current studies report that additional research needs to take place prior to making any recommendation for its use over the standard methods of evaluating and treating osteoporosis. Accordingly, collagen cross links testing performed on 11/17/17 was not likely to have been superior over the standard methods of evaluating this patients medical condition.

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 51-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma Assay (CPT code 84999 - unlisted chemistry procedure) provided on 1/17/17. 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 the DecisionDx-Melanoma Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx test has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Overall, there is not enough published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx-Melanoma Assay provided on 1/17/17 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: Upheld

Summary Reviewer 1


A 63-year-old female enrollee has requested reimbursement for an Anser ADA test performed on 5/12/15. The Health Insurer has denied this request indicating that the procedure at issue was considered investigational for evaluation of the enrollees Crohns disease with ileostomy. The physician reviewer found that monitoring patients on adalimumab with measurement of adalimumab levels and antibodies to adalimumab continues to be an area of intense investigation. In general, adalimumab levels correlate inversely with disease activity. Unfortunately, the target level of adalimumab necessary to achieve clinical benefit remains unknown. There is limited controlled data which have identified the optimal drug level and the issue remains speculative. More important than the drug level, is the effectiveness and response of the patient to the medication. In an attempt to answer this question in a patient failing therapy, one can set up a hypothetical table categorizing drug levels as high or low and antibody levels as high or low using the Anser ADA. Although appealing, this algorithmic approach has not been validated using prospectively controlled data. The control arm would be to increase the dose of the medication and make a switch when there is sufficient evidence of no response. In short, further studies need to be conducted before the efficacy of the testing can be confirmed.  In this case, the Anser ADA test was not likely to be more efficacious than standard therapy in the evaluation of the patients medical condition. Based upon the information set forth above, the procedure 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 53-year-old female enrollee has requested reimbursement for OVA1 testing performed on 5/19/15. 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 a lack of support for the services at issue in this clinical setting.  A 1.3 x 1.2 cm simple ovarian cyst and no free pelvic fluid, presenting in an asymptotic patient as an incidental finding, would typically be followed clinically, either by examination or by follow-up ultrasound.  If surgical evaluation was felt to be warranted and planned, then OVA1 testing could be utilized.  The medical evidence supports the use of OVA1 testing in order to help improve outcomes in those patients who already by clinical presentation warrant surgical evaluation of a pelvic mass to help better determine if preoperative evaluation and co-management with gynecologic oncology would be merited.  In this patients case, there was not a clinical or radiologic raised index of suspicion for this cyst representing a premalignant or malignant lesion.  The provider had not deemed that the mass required surgery based on the clinical/radiologic evaluation prior to OVA1 testing.  All told, OVA1 testing performed on 5/19/15 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: Overturned

Summary Reviewer 1 
 
A 23-year-old female enrollee has requested reimbursement for intraoperative monitoring on 
7/25/22. The Health Insurer has denied this request and reported that the service at issue was 
investigational for the treatment of the enrollees spastic quadriparesis secondary to cerebral palsy 
and spastic dislocation of the right hip. The physician reviewer found that the complex hip and 
femur surgery performed in this case involves not only bone and muscle tissue but proximity to 
major nerves that provide critical function to the lower extremities. These include the sciatic and 
femoral nerves. Damage to these nerves can result in paralysis, weakness, numbness, and chronic 
pain. Therefore, it is critical that the surgeon monitor the functioning of these nerves during this 
type of surgery. The alternative standard is to perform surgery without monitoring. In this clinical 
setting, performing complex hip and femoral surgery such as that done during varus deformity 
with neuromonitoring is more beneficial than not using neuromonitoring. Therefore, intraoperative 
monitoring on 7/25/22 was likely to have been more beneficial for treatment of the patients 
condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 51-year-old male has requested reimbursement for gene expression profiling performed on 5/04/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add a bit more to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. The melanoma is then classified based on the risk of metastasis. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients undergoing sentinel node biopsy. At this time, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year data of Balch. Based on the medical evidence, it is unclear whether DecisionDx-Melanoma data can be used to make clinical decisions. Therefore, gene expression profiling performed on 5/04/17 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: Overturned

Summary Reviewer 2

A 68-year-old male requested authorization and coverage for UroLift procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees benign prostatic hyperplasia (BPH). The physician reviewer found that there is sufficient support in the medical literature for the requested procedure in this clinical setting. The UroLift procedure has distinct advantages over other traditional surgical treatment in that it is outpatient, offers immediate improvement in the voiding pattern, often involves no significant blood loss and has less sexual adverse events such as retrograde ejaculation. The American Urological Association does not consider UroLift as an experimental procedure and supports its use in the treatment of patients who are diagnosed with BPH. All told, UroLift procedure is likely to be more efficacious than other treatment options for the treatment of this patient. Therefore, for the reasons stated above, the requested procedure 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: Upheld

Summary Reviewer 1


A 54-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees persistent asthma.   The physician reviewer found that bronchial thermoplasty is not considered standard of care for the treatment of asthma. In a recent publication noting the safety of the procedure, there was no difference in forced expiratory volume 1 (FEV1), emergency department visits, or hospital admissions between the bronchial thermoplasty group and the control group (Thomson, et al). Also, one clinical trial with sham bronchial thermoplasty documented placebo efficacy (Castro, et al). In this case, the provider states the patient has a progressive decrease in quality of life, but there is no documentation that the use bronchial thermoplasty would improve the long-term functional outcome of the patients condition. Accordingly, the requested bronchial thermoplasty 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 procedure 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 1

A 44-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/26/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination.  The physician reviewer found that there is evidenced base support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely to be more effective than had her examination been performed using two dimensional imaging alone. Based upon the information set forth above, the service at issue was likely to have been 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

The parent of a 12-year-old female enrollee has requested reimbursement for fecal calprotectin testing provided on 7/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that given the available medical literature, there is a role for fecal inflammatory markers including calprotectin in this clinical setting. The testing is a non-invasive means of gauging the presence of intestinal inflammation. Moreover, the use of fecal calprotectin values have become more widely used in inflammatory bowel disease centers and are routinely being incorporated into research studies given their value in distinguishing inflammatory from non-inflammatory symptoms. Considering the importance of determining response to treatment in patients with Crohns disease, the fecal calprotectin testing performed on 7/17/15 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 1

The parent of a 12-year-old female enrollee has requested reimbursement for fecal calprotectin testing provided on 7/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that the current medical literature suggests that this test is commonly used by providers in the care of Crohns disease patients. There are ample studies demonstrating the usefulness of calprotectin in the diagnosis and continued care of Crohns disease patients. All told, the peer-reviewed medical literature supports the utility of the fecal calprotectin testing performed on 7/17/15 as likely to have been more beneficial for evaluation of this patients Crohns disease than any available testing. 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 1


The parent of a 15-year-old male enrollee has requested reimbursement for the unlisted chemistry procedure, Anser IFX assay testing (CPT code 84999) performed on 11/17/15.  The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease.  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. Some evidence exists that low serum levels of infliximab (IFX) or adalimumab (ADA) 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 (Steenholdt, et al; Nanda, et al). 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. Given the lack of support in the peer-reviewed literature, the unlisted chemistry procedure, Anser IFX assay testing (CPT code 84999) performed on 11/17/15 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.