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

Summary Reviewer 

A 25-year-old transgender male enrollee has requested authorization and coverage for top surgery (mastectomy). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. World Professional Association for Transgender Health (WPATH) states that social transition is not a requirement before chest surgery for transgender men. The one year of social transition is only a requirement for reconstructive genital surgery. In fact, chest surgery often is the first medical procedure for transgender men, before hormones, and before the person first presents publicly as male. Distress is often high in young transgender men, and chest surgery for transgender men has been demonstrated to reduce distress. Olson-Kennedy and colleagues noted chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. There is sufficient support for the requested services in this clinical setting. Therefore, top surgery (mastectomies) is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 42-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 10/7/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees breast cancer examination.  The physician reviewer found that the digital breast tomosynthesis performed on 10/7/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Skaane and colleagues performed a large prospective screening trial To assess cancer detection rates, false-positive rates before arbitration, positive predictive values for women recalled after arbitration, and the type of cancers detected with use of digital mammography alone and combined with tomosynthesis. The authors concluded that 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. Given the support in the medical literature, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients breast exam than conventional mammogram.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is a 44-year-old female. In a letter dated 2/10/22, the provider reported that the 
patient has a medical history of sarcoidosis of the lung, liver disease, and fibromyalgia. The 
patient has requested authorization and coverage for Humira 40 mg/0.4 mL injectable every two 
weeks. The physician reviewer found that the submitted documentation supports the medical 
necessity  of  the  requested  medication.  Infliximab  is  a  chimeric  human-murine  antihuman 
antibody that specifically blocks the effect of tumor necrosis factor-alpha (TNF-alpha). Current 
medical literature suggests that infliximab may be useful in selected patients with pulmonary and 
extrapulmonary sarcoidosis refractory to glucocorticoid therapy, and includes positive trials of 
Humira, which has a similar mechanism of action to infliximab, in the treatment of pulmonary 
and cutaneous sarcoidosis and sarcoid arthritis. Crommelin and colleagues report, Adalimumab 
is an effective alternative for patients intolerant to infliximab. The switch to adalimumab 
achieved clinical improvement in 39% and stabilization in 33% of patients intolerant to infliximab. 
Further research is needed to develop guidelines on how to use adalimumab for sarcoidosis in 
terms of dosing regimen. In a small, open-label study, Sweiss and colleagues reported that 
adalimumab improved refractory pulmonary sarcoidosis and was well tolerated. Pariser and 
colleagues reported that adalimumab is likely to be an effective and relatively safe suppressive 
treatment for cutaneous sarcoidosis. In this case, given the patients risks for side effects with 
the long-term use of prednisone, the requested medication is medically indicated. Therefore, 
Humira 40 mg/0.4 mL injectable every two weeks is medically necessary for the treatment of this 
patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The patient is a 58-year-old male who has been diagnosed with prostate cancer. On 4/27/17, pathology report noted prostatic carcinoma, with highest Gleason score 3+3=6. Per the records, three cores were positive. The patient has requested reimbursement for Oncotype DX Prostate Assay performed on 9/29/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  There is a lack of support for the services at issue in this clinical setting. This test has not been validated with prospective randomized clinical trials to change outcomes and impact survival and or quality of life. The medical evidence does not support the use of this molecular test to determine the appropriateness of observation or active surveillance. Therefore, Oncotype DX Prostate Assay performed on 9/29/17 was not likely to be more efficacious 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 22-year-old male enrollee has requested reimbursement for substance use partial hospitalization program (PHP) services provided from 9/19/16 through 10/13/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that based on the Level of Care Utilization System (LOCUS) criteria, as of 9/19/16, the patient met criteria for treatment in a less restrictive environment. The patients risk of harm score is two (2), low risk of harm. There was no documentation indicating that the patient had any suicide attempts. On 9/19/16 the patient had an appropriate mood, was participating in treatment, and did not have any suicidal ideation. The patients functional status score is three (3), moderate impairment. Due to the patients substance use, he has had a significant deterioration in his ability to fulfill responsibilities and obligations to a job or school. The patients medical, addictive and psychiatric co-morbidity score is three (3), significant co-morbidity. The patient had a co-morbidity of polysubstance use, depression, and anxiety. The patient did not have any serious medical problems and was medically stable. The patients recovery environment score is three (3), moderately stressful environment. The patient has significant discord with his family and his father recently passed away. The patients level of support score is three (3), limited support in environment. The patients treatment history score is three (3), equivocal response to treatment and recovery. The patient improves enough to be stepped down from RTC on 9/19/16. The patient has been sober since 8/31/16. The patients engagement and recovery status score is two (2), positive engagement and recovery. The documentation reports that the patient engaged and participated in treatment.  Based on these criteria, the patient has a total score of 19, which would meet criteria for an IOP. The patient continued to require treatment for his substance use, depression, and anxiety, but the patient could have continued treatment in a less restrictive environment. Therefore, substance use PHP services provided from 9/19/16 through 10/13/16 were not medically necessary for treatment of the patients medical condition. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 26-year-old female enrollee has requested reimbursement for CPT code 81291 performed on 10/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a family history of a clotting disorder. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue. The American College of Obstetricians and Gynecologists notes that there is a lack of association between either heterozygosity or homozygosity for the methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism and negative pregnancy outcomes, including any increased risk of venous thromboembolism. Thus, screening with either MTHFR mutation analyses or fasting homocysteine levels is not recommended. In sum, CPT code 81291 performed on 10/11/17 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: Upheld

Summary Reviewer 1


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 patients provider recommended a tissue sample be sent for the Decision Dx melanoma assay which evaluates genes for certain markers and then the lesion can be further stratified to determine if it is high risk for metastasis. This test has shown some impressive accuracy in thin melanomas like this patients tumor. However, the results of the test are indeterminate. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Further, there is a lack of medical literature to support its use in the care of patients with thin melanomas to effect health outcomes. Since this test does not provide a benefit greater than established tests on patient outcomes, and is not currently the standard of care, there needs to be clinical trials to determine the utility of the results of the test. In the absence of this data, 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 63-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy less than 12 months due to non-liver-related conditions.  Additionally, treatment of patients before they progress to cirrhosis is advantageous.  Based on evidence of safety and efficacy in the published literature, and clinical guidelines, the requested medication Harvoni 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: Overturned

Summary Reviewer 1

A 44-year-old male has requested authorization and coverage for total disc arthroplasty at the levels of L4-L5 and L5-S1. 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 there is sufficient support for the requested services in this clinical setting. This patient has ongoing axial back pain. Epidural steroid injections did not provide relief. There is no radiating component. The patient has attempted all reasonable nonsurgical treatments. There is a lack of treatment options in this setting. The medical literature supports the requested services in this patientas case. Therefore, total disc arthroplasty at the levels of L4-L5 and L5-S1 is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 53-year-old female enrollee has requested reimbursement for the homocysteine testing performed on 3/9/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees peripheral neuropathy. The physician reviewer found that there is support for testing patients with distal sensory symptoms without a clear etiology for treatable causes of a length-dependent peripheral neuropathy. One such cause relates to elevated homocysteine levels. If detected, this can be treated with B12 even in the context of normal B12 levels. Thus, although there is limited data demonstrating improved health outcomes with homocysteine testing in this clinical setting, some literature has linked homocysteine levels to treatable cases of neuropathy. Accordingly, the homocysteine testing performed on 3/9/16 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 42-year-old female enrollee has requested reimbursement for the Ova 1 test performed on 1/16/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees risk for ovarian cancer.  The physician reviewer found that while malignant masses in the adnexa require surgical removal, other masses may not. Specific features of history, family history, CT, and ultrasound findings assist in making this determination. However, this information may be lacking and further testing is needed. The most well-known marker for ovarian cancer in CA 125, but up to 50% of patients with stage I ovarian cancer have a normal value and a number of other malignant and benign conditions can cause an elevated level as well (Bast, et al). The Ova 1 test incorporates five biomarkers including CA 125 for a more thorough tumor assessment. In one study from Ueland and colleagues, the authors reported that adding the Ova 1 to a physician assessment correctly identified 70% of cancers missed by gynecologists. Although there was a lack of specificity since 261 benign tumors were also referred gynecologic oncology, the authors concluded that the use of the Ova 1 with standard clinical parameters improved detection of malignancy. Accordingly, the use of the Ova 1 was likely to have been more beneficial in this patients evaluation and treatment than any available standard modality. 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: Upheld

Summary Reviewer 1 
 
A 32-year-old female enrollee has requested authorization and coverage for a prescription for 
Qulipta  60  mg tablets. The  Health  Insurer has  denied this  request  and  reported  that  the 
requested medication is investigational for the treatment of the enrollees headaches. The 
physician reviewer found that Edvinsson and colleagues report that calcitonin gene-related 
peptide (CGRP) plays a crucial role in migraine pathophysiology and is now established as an 
important target for both preventive and acute treatment. The authors further note that CGRP-
targeting  monoclonal  antibodies  that  bind  either  the  CGRP  receptor  or  the  CGRP  ligand 
effectively prevent migraine attacks. Small molecule CGRP receptor antagonists are a newer drug 
class called gepants. The U.S. Food and Drug Administration (FDA) approves the use of Qulipta 
(atogenpant), a CGRP receptor antagonist, for the preventive treatment of episodic migraine in 
adults. Ailani and colleagues report that atogepant, an orally administered gepant, demonstrated 
efficacy and tolerability in the preventive treatment of migraine in a 12-week randomized, 
double-blind, placebo-controlled, parallel-group study of subjects with episodic migraine. The 
authors further noted that all atogepant dosage levels were more effective than placebo at 
reducing monthly migraine days and well tolerated. The American Headache Society notes that 
patients with migraine should be considered for preventive treatment in any of the following 
situations: (1) attacks significantly interfere with patients daily routines despite acute treatment, 
(2) frequent attacks, (3) contraindication to, failure, or overuse of acute treatments, with overuse 
defined as ten or more days per month for ergot derivatives, triptans, opioids, combination 
analgesics, and a combination of drugs from different classes that are not individually overused, 
(4) fifteen or more days per month for nonopioid analgesics, acetaminophen, and nonsteroidal 
anti-inflammatory drugs (NSAIDs), (5) adverse effects with acute treatments, or (6) patient 
preference. The AHS further notes that treatment plans involving the preventive use of gepants 
should be based on regimens used in clinical trials and personalized according to the needs of 
individual  patients.  In  this  case,  the  patient  has  a  history  of  episodic  migraines  that  are 
debilitating despite acute treatment, fulfilling the AHS criteria for preventative treatment. In this 
clinical setting, a treatment plan involving the preventive use of gepants that is personalized 
according to the needs of the individual patient, as recommended by the AHS, is likely to be more 
beneficial  than  any  available  standard  therapy  for  the  patients  condition.  Therefore,  a 
prescription for Qulipta 60 mg tablets is likely to be more beneficial for treatment of the patients 
condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 35-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. According to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for treating hepatitis C, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Moreover, the combination of ledipasvir/sofosbuvir Harvoni is recommended for hepatitis C genotype 4 patients based upon trial studies (Kapoor, et al; Abergel, et al). Abergel and colleagues reported data from an open-label single-arm study including 22 HCV genotype 4 infected, treatment-naive patients (only 1 with cirrhosis) with an SVR rate of 95% (21/22) at 12 weeks. Therefore, the request for Harvoni is medically necessary for treatment of the patients HCV genotype 4 infection. For the reasons provided, 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 2
A 60-year-old female enrollee has requested authorization and coverage for Botox. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees chronic migraine headaches The physician reviewer found that there is a lack of support for the requested medication in this patients case. There is no documentation provided that supports that the patient was previously having 15 headache days per month. While Botox is indicated for the treatment of chronic migraines in some patients, the medical records in this patients case do not support the claim that the patient was suffering from chronic migraines. Although it was noted that the patient was previously treated for Botox, there is no documentation to support its efficacy for continued treatment. In sum, Botox is not likely to be more effective than other available treatment options for the treatment of this patient. Therefore, for the reasons stated 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: Upheld

Summary Reviewer 2
A 56-year-old female enrollee has requested reimbursement for the Foundation One genetic testing provided on 1/12/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees recurrent ovarian cancer.  The physician reviewer found that per National Comprehensive Cancer Network (NCCN) compendia and American Society of Clinical Oncology (ASCO), chemotherapy sensitivity assays have a category 3 recommendation as there is a lack of robust evidence that their use translates into a benefit for the patient. Moreover, these chemotherapy sensitivity assays are not considered the standard of care. There are numerous regimens to choose from in this clinical setting without the use of a chemotherapy sensitivity assay, based upon well controlled peer-reviewed literature. Thus, the Foundation One genetic testing performed on 1/12/15 was not likely to have provided this patient with an improved health outcome when compared to standard available therapies. Based upon the information set forth above, I have determined 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.