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

Summary Reviewer 2


A 44-year-old female enrollee has requested reimbursement for BRCA testing performed on 3/17/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees risk of cancer.  The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. This patient does not meet established guidelines for testing for BRCA mutations (Robson, et al). She does not have a personal history of cancer, is not identified as being from a high risk ethnic group such as Ashkenazi Jewish and has identified one second or later degree relatives on both sides of the family that are over the age of 50. A third relative is mentioned but no information is provided. In this clinical setting, pre-test counseling would likely be more beneficial than BRCA testing with a genetic risk assessment based on personal and family history. Therefore, the BRCA testing performed on 3/17/16 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 29-year-old female enrollee has requested reimbursement for allergen specific immunoglobulin G (IgG) (RAST/ELISA) for routine allergy testing performed on 3/22/19. 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 multiple evidence based studies have demonstrated that immunoglobulin G (IgG) testing to foods is an unproven method of testing for food intolerances as well as food allergy. IgG antibodies are proteins produced by the immune system in response to exposure to external triggers, like pollens, foods or insect venoms. Their presence reflects exposure to these triggers, not disease that results from exposure. IgG antibodies to food are commonly detectable in healthy adult patients and children, whether food-related symptoms are present or not. There is a lack of credible evidence indicating that measuring IgG antibodies is useful for diagnosing food allergy or intolerance, or that IgG antibodies cause symptoms. The only exception is that gliadin IgG antibodies can be used to monitor the success of avoiding gluten in people with proven celiac disease. Testing for allergen specific IgG is not a recommended method of evaluating and treating a patient for suspected food allergy or food intolerance. Thus, allergen specific immunoglobulin G (IgG) (RAST/ELISA) for routine allergy testing performed on 3/22/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 55-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/02/16.  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 the current medical evidence supports the service at issue in this patients case.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Thus, digital breast tomosynthesis performed on 9/02/16 was likely to have been more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the service 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: Upheld

Summary Reviewer 1

A 57-year-old female enrollee has requested reimbursement for the DecisionDx-Melanoma Assay provided on 7/20/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that there is a lack of support for the services at issue in this patients case. DecisionDx-Melanoma Assay is a gene expression profile test which was designed to predict distant metastasis in stage I and stage II melanoma patients. DecisionDx-Melanoma assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class 1 (i.e., low risk of metastasis) or Class 2 (i.e., high risk of metastasis). At this time, the medical evidence has not demonstrated the superior efficacy of the services at issue. There is a lack of peer-reviewed published studies demonstrating that the DecisionDx-Melanoma Assay is superior over other modalities in this clinical setting. Therefore, DecisionDx-Melanoma Assay performed on 7/20/18 was not likely to have been more effective than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1 
 
A 31-year-old female has requested reimbursement for lab tests that measure the levels of 
medication, adalimumab (ADA) performed on 8/1/22. The Health Insurer has denied this request 
indicating that the testing at issue was considered investigational for evaluation of the insureds 
ulcerative colitis. The physician reviewer found that the use of testing for the assessment of this 
patients adalimumab (ADA) drug level and anti-ADA antibody level is supported by the current 
guidelines from the American Gastroenterological Association (AGA) and American College of 
Gastroenterology (ACG) (Feuerstein, et al.; Rubin, et al.). The records indicate that this patient 
was on ADA for the treatment of ulcerative colitis. The patient reportedly demonstrated ongoing 
symptoms of active ulcerative colitis, and showed a markedly elevated C-reactive protein, which 
are accepted markers for uncontrolled ulcerative colitis (Rubin, et al.). Given the patients elevated 
C-reactive protein and ongoing symptoms, which are consistent with active or uncontrolled 
ulcerative colitis, the patient was at risk for complications of ulcerative colitis. According to the 
AGA, In adults with active inflammatory bowel disease treated with anti-tumor necrosis factor 
agents, the AGA suggests reactive therapeutic drug monitoring to guide treatment changes 
(Feuerstein, et al.). According to the AGA guidelines, drug concentration and anti-drug antibody 
levels should be checked if there is a loss of response to an anti-tumor necrosis factor (TNF) 
medication, such as ADA, with a subsequent change in management. Per the ACG guidelines, 
The patient with nonresponse or loss of response to therapy should be assessed with therapeutic 
drug monitoring to identify the reason for lack of response and whether to optimize the existing 
therapy or to select an alternate therapy (Rubin, et al.; Roda, et al.; Irving and Gesce.). Assessment 
of whether the patients ADA dose should have been increased or changed to an alternative therapy 
was appropriate per the ACG and AGA guidelines. For these reasons, the lab tests that measure 
the levels of medication, adalimumab (ADA) performed on 8/1/22 were likely to be more 
beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 62-year-old male with hyperlipidemia, diabetes and coronary artery disease including prior stent placement. There is documented intolerance to several -statins and Zetia. A clinic note dated 10/3/16 documents a low density lipoprotein (LDL) cholesterol of 99 mg/dl while taking pravastatin 80 mg per day. The patient has requested authorization and coverage for Repatha. The Health Insurer has denied this request as not medically necessary indicating the patient must first try the formulary alternative Praluent. Based on the records provided the patient is a 62-year-old male with known coronary disease, intolerance to several statins and Zetia, as well as suboptimal LDL control on maximum tolerated pravastatin dose. In this circumstance PSCK9 inhibitors have been shown to be safe, effective at further reducing LDL levels and result in improved cardiac outcomes. Repatha and Praluent have been demonstrated to be effective in this clinical setting, however there is a lack of controlled trials comparing the relative efficacy of these two medications (Sabatine, et al; Robinson, et al). The use of Repatha over Praluent is not clinically indicated, given that there is no documented intolerance or contraindication to the formulary preferred PCSK9 inhibitor. For the reasons provided, the request for Repatha is not medically necessary for treatment of the patients medical condition.  For the reasons provided, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

The patient is a 46-year-old female with a three-year history of chronic neck pain radiating to the bilateral upper extremity with numbness in both hands and feet. A 3/30/17 cervical spine magnetic resonance imaging (MRI) impression documented straightening of the normal cervical lordotic curve. At C5-6, there was subacute reactive marrow beneath the left endplates, 1-2 mm retrolisthesis, 2 mm broad-based disc bulge with no impingement, lateral disc osteophytic spurring, greater on the left, and mild to moderate left neuroforaminal narrowing. At C6-7, there was a 1-2 mm central disc protrusion, and minimal right uncovertebral hypertrophic changes but no significant stenosis. The 3/22/17 provider noted that the patient was seen for follow-up. She underwent facet blocks from C5-7 three times and did well each time, but her symptoms recurred. X-rays showed greater collapse in the C5-6 level than when she was first evaluated, as well as C6-7 intervertebral collapse. She was not responding to conservative management any longer. A 3/22/17 cervical spine x-ray report documented loss of disc height at C5-6, and mild motion on flexion/extension views from C2-3 through C4-5. A 4/13/17 operative report indicated that anterior cervical discectomies were performed at C5-6 and C6-7 with insertion of the intervertebral disc replacement prosthesis C5-6 and C7. The patient has requested reimbursement for cervical artificial discectomy performed on 4/13/17. The Health Insurer has denied this request indicating that the surgery at issue was considered investigational. In the peer-reviewed medical literature, Davis and colleagues performed a prospective, randomized, controlled multicenter clinical trial on two-level symptomatic degenerative disc disease. The authors found that use of cervical arthroplasty at two contiguous levels provided advantages over two-level anterior cervical discectomy and fusion. Coric and colleagues reported that the use of anterior cervical surgery for contiguous two-level pathology as safe and effective. The authors concluded that total disc replacement was superior to anterior cervical discectomy and fusion for the treatment of two-level contiguous pathology at five years. Moreover, the US Food and Drug Administration (FDA) has approved the use of the Mobi-C and Prestige discs for well selected patients who have failed conservative treatment. This patient met the FDA and evidence based medical criteria for the two level artificial disc replacement performed on 4/13/17. Therefore, the cervical artificial discectomy performed on 4/13/17 was 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 surgery at issue was 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 45-year-old female enrollee has requested authorization and coverage for Tazorac 0.1% cream.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found this patient has been diagnosed with keratosis pilaris, and she has been stably treated with Tazorac for greater than 10 years.  Keratosis pilaris is a common genetic condition resulting in build-up of the outer layer of skin at hair follicles, typically on the upper arms, thighs, buttocks and occasionally cheeks.  Treatment is most successful with keratolytic agents, including ammonium lactate, urea and salicylic acid preparations, or retinoid creams.  She has already tried and failed the typical preparations, but had success with Tazorac, a retinoid cream.  The request for coverage of this medication should be continued, as she has been treated successfully and stably for years with this medication and there is a lack of alternatives.  All told, Tazorac 0.1% cream is medically indicated for the treatment of this patient.  Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

The patient is a 56-year-old male with a ventricular fibrillation cardiac arrest with anterior myocardial infarction. He was resuscitated and referred for percutaneous coronary intervention of left anterior descending artery with drug eluting stent. The patient subsequently had recurrent ventricular fibrillation requiring both lidocaine and amiodarone load to control. He was referred for repeat catheterization which showed distal narrowing of stented segment of left anterior descending artery which was treated with angioplasty and a severe non-culprit lesion in right coronary artery was treated with stenting as well. The patient has requested reimbursement for wearable cardioverter defibrillator. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of this patient.  There is sufficient support for the device at issue in this clinical setting. Given the recurrent episodes, the requirement for multiple anti-arrhythmic medications and the predisposition to life-threatening rhythm disturbances with ischemia, he remained at high risk for sudden death if he were to have early stent thrombosis and/or recurrent ischemia. In the period where medical management and subsequent reassessment of left ventricular function needs to occur (first three months post infarction), the use of an external defibrillator vest is reasonable in the event of another episode of ventricular fibrillation and sudden cardiac death to deliver immediate counter shock therapy. At three months, left ventricular ejection fraction can be reassessed by echocardiogram, along with any further ongoing ventricular rhythm disturbances by Holter monitoring, and a decision about the need for long-term automatic implantable cardioverter defibrillator therapy can be made at that time. In the interim, an external defibrillator vest was a reasonable interim solution to protect against sudden cardiac death. Therefore, the wearable cardioverter defibrillator was likely to have been more effective than other treatment options.  Based upon the information set forth above, the device at issue was 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 63-year-old male enrollee has requested reimbursement for monitored anesthesia care provided on 10/21/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient does not have any documented significant disease history. The request is for reimbursement for monitored anesthesia care during routine screening colonoscopy with polypectomy. According to the American Society of Anesthesiologists guideline for anesthesia care during endoscopic procedures, monitored anesthesia care is warranted in prolonged or painful procedures such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that monitored anesthesia care is more likely necessary in patients with a failed history of moderate sedation for the procedure or psychological impediments to cooperation. The provided records do not support any of these criteria, or other criteria in the literature, such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, age greater than 70, pregnancy, increased aspiration risk, American Society of Anesthesiologists class III or higher, or morbid obesity. According to the most recent guidelines from the American Society for Gastrointestinal Endoscopy, during endoscopic procedures (unlike surgery) consciousness during the procedure is acceptable and is the goal during most procedures, and monitored anesthesia care is recommended for prolonged procedures requiring deep sedation, previously anticipated intolerance to standard sedatives, American Society of Anesthesiologists class IV or V, or risk for airway obstruction due to anatomic variant. For these reasons, the submitted records do not support the medical necessity of monitored anesthesia care in this case. Therefore, monitored anesthesia care provided on 10/21/19 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

The patient is a 59-year-old female who was diagnosed with a cutaneous melanoma on her left chest wall in February 2016. At that time, she was found to have a non-ulcerating melanoma with Breslow thickness of 1.28 mm, Clark level IV. The patient has requested reimbursement for gene testing performed on 5/12/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. The prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add a bit more to these statistics. DecisionDx-Melanoma assay is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based upon the risk of metastasis. Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification in patients undergoing sentinel node sampling. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year data of Balch. Most importantly, it is not clear if the assay can be used to make clinical decisions. Thus, gene testing performed on 5/12/16 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1
The parent of a nine-year-old transgender male enrollee has requested authorization and coverage for Supprelin LA KIT 50 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees gender dysphoria. The physician reviewer found that blocking pubertal development has rapidly become more widely available and is now part of the clinical management guidelines for adolescents in addition to cross sex hormones and surgery (at older ages) as this leads to improved psychological functioning of transgender adolescents. Per standards of care, by the Endocrine Society guidelines and World Professional Association of Transgender guidelines, puberty suppression is indicated in early puberty if desired by the minor in order to prevent irreversible physical changes including breast development in transgender males. Puberty suppression also will likely help decrease self-harm in this vulnerable population as menstruation and breast development in a transgender boy is very emotionally difficult as their body is growing more incongruent to their identity. Thus, gonadotropin-releasing hormone analogs are safe and a reversible medical intervention that should be used to relieve distress that gender dysphoric adolescents experience when their secondary sex characteristics develop. Accordingly, Supprelin LA KIT 50 mg is likely to be more effective than other available treatment options for the treatment of this patients medical condition.Based upon the information set forth above, the requested medication 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

The parent of a four-year-old male enrollee has requested authorization and coverage for Botox 100 units. 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 Botox injections have been successfully used for children with constipation due to Hirschsprung disease or anal achalasia. They are now being used in some centers for the management of refractory functional constipation. In this case, anorectal manometry has not yet been performed to assess for anal achalasia or non-relaxing internal anal sphincter, which, if present, would provide a clearer indication for Botox injection. Even in the absence of anal achalasia, refractory functional constipation which has not responded to medical therapy, and which otherwise would be treated with more invasive surgical procedures such as cecostomy, would support the use of Botox.  However, based on the clinical data provided, there was still some question as to whether senna would be an effective intervention, as well as whether milk of magnesia would be tolerated by the patient. There is also a mention of the use of enemas and suppositories in the past, but no indication as to why they could not be used more aggressively prior to moving forward with anal sphincter Botox injection. Therefore, in the absence of known anal achalasia, and in light of the possibility that other medical treatments might still be effective, the superior efficacy of the requested services over standard treatments has not been established. Therefore, J0585 - Botox 100 units are not likely to be more beneficial than any available standard therapy.