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

Summary Reviewer  
The patient is a 64-year-old male with a history of left hip and leg symptoms. The patient has 
requested reimbursement for left lateral femoral nerve surgery performed on 11/15/18. The 
physician reviewer found that California law defines an emergency medical condition as a 
medical condition manifesting itself by acute symptoms of sufficient severity (including severe 
pain) such that the absence of immediate medical attention could reasonably be expected to 
result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious 
impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Meralgia 
paresthetica is a pain syndrome that results from compression or entrapment of the lateral 
femoral cutaneous nerve. Patients can complain of pain and/or numbness in the region of the 
lateral  femoral  cutaneous  nerve.  A  number  of  treatment  options  are  available,  including 
medications, injections, pulse radiofrequency neuromodulation, neurostimulation, neurolysis 
and neurectomy. Surgery in the form of neurolysis or neurectomy is typically reserved for 
patients who have failed non-surgical strategies. Based on the available literature and the 
understanding of the pathology as an entrapment syndrome of a purely sensory nerve, it is 
difficult to characterize meralgia paresthetica as a medical emergency. Based on the records, the 
definition of emergency medical condition as a medical condition manifesting itself by acute 
symptoms does not apply in this case. The patients symptoms were present for greater than six 
years. This was not an acute problem. After careful evaluation of this case, a prudent layperson, 
who possesses an average knowledge of health and medicine, would not reasonably expect the 
absence of immediate medical attention to result in the following in this case: (i) placing the 
health of the individual in serious jeopardy, (ii) serious impairment to bodily functions, or 
(iii) serious dysfunction of any bodily organ or part. Therefore, left lateral femoral nerve surgery 
performed on 11/15/18 was not emergent in nature.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 64-year-old male enrollee has requested reimbursement for injection, immune globulin, Gammagard liquid, non-lyophilized, (e.g., liquid) 500 mg from 11/2/15 through 11/6/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees anti-GM1 polyneuropathy and Sjogrens syndrome. The physician reviewer found the current literature supports IVIG treatment in this clinical setting. As with most neuropathies, the cause of the neuropathy is thought to be autoimmune in nature. The use of IVIG is considered standard therapy in the treatment of neuropathies. Therefore, according to the current standard of care, the injection, immune globulin, (Gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg from 11/2/15 through 11/6/15 was likely to be more effective than other therapies available for treatment of this patient. Based upon the information set forth above, the services at issue were 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 3

The patient is a 58-year-old female under evaluation and treatment for GERD. The patient is considered to have both typical and atypical symptoms with only a partial response to proton pump inhibitor (PPI) therapy. Upper endoscopy showed no Barretts and a 1 cm hiatal hernia without esophagitis. Barium esophagram suggested normal peristalsis. The patient underwent a pH study of the esophagus which was positive for pathologic reflux with acidification of the esophagus 13% of the time. There was a poor correlation between acid reflux events and the timing of symptoms. The patient has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational. The U.S. Food Drug Administration (FDA) approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate GERD and a hiatal hernia less than 3 cm. This patient has a poor association between symptoms and episodes of pathologic reflux. In addition, the patient has atypical symptoms and only a partial response to PPI therapy. These findings indicate that the patient will not experience improvement with a surgical approach to her reflux disease beyond what she has experienced with PPI therapy. For these reasons, the requested LINX procedure 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 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: Overturned

Summary Reviewer 1

The patient is a 61-year-old female with a history of recurrent ovarian cancer diagnosed with multiple prior lines of therapy. Her tumor was submitted for molecular profiling with FoundationOne testing on 3/16/17. The patient has requested reimbursement for blood testing performed on 3/16/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational. Individualized molecular tumor profiling holds the promise of enabling personalized selection of molecularly targeted treatment based on the specific genotype identified. Several platforms are available, including the FoundationOne, Caris Target Now, and SNaPshot technology. The National Comprehensive Cancer Network (NCCN) guidelines recommend tumor molecular testing prior to initiation of therapy for recurrent or persistent ovarian cancer, if not previously done. Testing should include BRCA1 and BRCA2, homologous recombination pathway genes, and microsatellite instability (MSI) or DNA mismatch repair (MMR). Molecular profiling is now considered a standard of care in patients with recurrent or persistent ovarian cancer. Accordingly, the blood testing performed on 3/16/17 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 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 breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breast tissue was described as extremely dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  In sum, digital breast tomosynthesis performed on 9/02/16 was likely to have been more effective than other modalities for 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: Overturned

Summary Reviewer 2

A 64-year-old female enrollee has requested reimbursement for genetic testing performed on
1/27/20. 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 understanding the molecular drivers of cancer progression and metastases is an area of ongoing
and active research, predominantly driven by the goal of identifying specific genomic aberrations
that may ultimately result in individualized cancer treatment. In addition to likely providing
prognostic information, the value of next generation sequencing to predict candidates for specific
mutation-driven treatment holds promise. Patients with inflammatory and metastatic breast
cancers benefit from next-generation sequencing to identify markers that may indicate benefit from
targeted treatment or clinical trials. Therefore, genetic testing performed on 1/27/20 was likely to
have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a 14-year-old female enrollee has requested reimbursement for scoliosis bracing provided on 1/10/18. The Health Insurer has denied this request indicating that the equipment at issue was not medically necessary for treatment of the enrollees scoliosis. The physician reviewer found that the most common form of scoliosis, or spinal curvature, is idiopathic scoliosis, and it is further categorized by age grouping. Adolescent idiopathic scoliosis is generally discovered in children over ten years of age. By definition, the curvature must measure at least 10 degrees in one of the three directions. Mild curvature may go unnoticed, but significant curvature may be associated with respiratory difficulties, pain, and functional impairment. Bracing is considered to be the standard of care for idiopathic scoliosis in adolescents with immature skeleton and Cobb angle less than 40 degrees. This patient is within the range of therapy where bracing remains the treatment of choice, and is considered to be the standard of care. Therefore, scoliosis bracing provided on 1/10/18 was medically necessary for the treatment of this patient. Therefore, the equipment at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 60-year-old female enrollee has requested authorization and coverage for Taltz. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriatic arthritis. The physician reviewer found that this patient failed therapy with Celebrex, methotrexate and Stelara, and she did not tolerate Enbrel and Humira. The records do not document that she has tried and failed or has a contraindication the Health Insurers preferred therapy, Cosentyx (secukinumab). Per Patel and colleagues, based on available evidence, secukinumab offers an effective new addition to the psoriatic arthritis treatment repository. Mease and colleagues noted subcutaneous secukinumab provided sustained improvements in the signs and symptoms, quality of life and physical function of patients with active psoriatic arthritis with low rate of radiographic disease progression through three years. Taltz has not been demonstrated to be superior to Cosentyx in terms of efficacy or safety. Thus, Taltz is not medically necessary for the treatment of this patient. Therefore, 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: Upheld

Summary Reviewer 3

A 28-year-old female enrollee has requested reimbursement for the Anser ADA testing performed on 12/1/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the use of Anser ADA testing has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. The effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with adalimumab may experience drug reactions or loss of response, but the appropriate method for determination of the cause for these is not clear. The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature (Karmiris, et al; Imaeda, et al). The study by Karmiris and colleagues found no direct relationship between trough serum adalimumab concentration or anti-adalimumab antibody and short-term treatment efficacy. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. In sum, there is a lack of medical literature supporting Anser ADA as 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 2

A 48-year-old female enrollee has requested reimbursement for electroretinography performed on 8/17/18. 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 the medical records indicate that the patient has a history of diabetes and diabetic retinopathy. The biggest ophthalmic risk from diabetes is diabetic retinopathy, which can also lead to diabetic macular edema. If not successfully treated, these conditions can lead to permanent loss of vision.  Most ophthalmologists in the United States diagnose diabetic retinopathy and diabetic macular edema with a combination of physical examination of the retina through dilated pupils with indirect ophthalmoscopy and optical coherence tomography.  Fundus photographs may be used to document the extent or severity of diabetic retinopathy for progression. Optical coherence tomography angiography and fluorescein angiography are used to document poor vascular perfusion or leakage in diabetic retinopathy/diabetic macular edema. Electroretinography uses a flash of light to generate an electromagnetic signal within the retina, which is then captured by an electrode on the surface of the eye. Jansson and colleagues noted photopic full-field electroretinography and spectral-domain optical coherence tomography derived retinal thickness parameters have limited clinical value in the staging of diabetic retinopathy. There is a lack of evidence indicating that electroretinography is a functionally useful tool in diagnosing diabetic retinopathy at this time. In sum, electroretinography performed on 8/17/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 34-year-old female with a history of back pain. The patient has requested authorization and coverage for laminotomy (hemilaminectomy) L4-5. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the patient has a documented herniation at L4-5, causing persisting mass effect upon the left L5 nerve root. This has been present for a year and is slightly improved on the recent MRI. She has failed conservative treatment and continues to be symptomatic at this time. The surgical level has been confirmed with epidural steroid injections. The provider has advised surgery with decompression of the nerve root. A review of the literature indicates sufficient decompression of the nerve root canal is necessary when operating on patients with lumbar disc herniation with lumbar lateral recess stenosis. Microsurgical techniques and percutaneous techniques are common. Endoscopic techniques are also available. The provider has requested laminotomy (hemilaminectomy) at L4-5 for decompression of the nerve root. The request is supported by the medical literature. Therefore, the requested laminotomy (hemilaminectomy) L4-5 is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 62-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 4/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found the breast tomosynthesis performed on 4/23/15 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is support in the medical literature for the use of breast tomosynthesis compared to conventional mammogram due to improved cancer detection rate. According to 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.  Based on the medical literature cited above, the use of breast tomosynthesis 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 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 3

A 62-year-old male enrollee has requested reimbursement for homocysteine, Factor V Leiden and methylenetetrahydrofolate reductase (MTHFR) testing provided on 4/28/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees right lower extremity deep vein thrombosis (DVT). The physician reviewer found the homocysteine, Factor V Leiden and MTHFR testing provided on 4/28/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the testing at issue in this clinical setting. Patients with DVT have a high prevalence of inherited thrombophilic disorders and the testing at issue is recommended. In this case, the patient presented with spontaneous DVT of the right femoral and popliteal veins. In this clinical setting, the testing at issue 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 
 
The parent of a 16-year-old female enrollee has requested reimbursement for autonomic testing 
performed on 8/19/20. 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 medical evidence supports the services at issue in this clinical setting. 
Prior to engaging in any course of treatment, it is imperative to have a working diagnosis. Despite  being recognized as a very real clinical entity, the underlying etiology (or etiologies) of postural 
orthostatic tachycardia syndrome (POTS) remain unclear, and there continues to be debates 
about whether POTS is due to dysautonomia from peripheral nerve dysfunction versus central 
nervous system dysfunction versus both. While salt tablets have been used empirically, there is 
considerable room in the therapeutic armamentarium to consider clinical trials such as the 
hyperpolarization-activated cyclic nucleotide-gated (HCN) channel blocker ivabradine. The first 
step in the care of a patient with POTS-like symptoms is a thorough evaluation of the autonomic 
nervous system, which was performed in this patients case.  Therefore, autonomic testing 
performed on 8/19/20 was likely to have been more beneficial than any available standard 
therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 55-year-old male enrollee has requested authorization and coverage for the LINX lower esophageal sphincter augmentation device. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that appropriate patient selection is crucial before anti-reflux procedures. In prelude to surgical intervention for GERD, currently upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery (Jobe, et al). This patient has undergone much of this pre-operative assessment. The records provided for review demonstrate that this patient has GERD as based on pH recording, and that his response to maximized acid suppression treatment has been sub-optimal. The patient has no dysphagia, Barretts, large hiatal hernia, or absolute surgical contraindications that disqualify him for LINX placement. It can be anticipated that the benefits of ant-reflux surgery with LINX implantation in this patients case will exceed available standard therapy. For these reasons, the requested LINX lower esophageal sphincter augmentation device 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 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 33-year-old male enrollee has requested reimbursement for Prometheus Anser ADA diagnostic testing performed on 5/19/14.  The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the patient was placed on Humira after the identification of a clinical and mucosal relapse while on Cimzia. In addition to 6-MP the patient was placed on an escalated dose of Humira. The patient began to show clinical improvement. There is a lack of controlled data concerning the testing for antibodies or adalimumab levels in this clinical scenario. There is a lack of established data indicating what drug level to target with adalimumab in the setting of an ileocolonic resection to prevent relapse. Given the lack of guidance in the peer-reviewed literature of when to test, how often to test, what to look for, and what to do with the results, the testing at issue was not likely to be more beneficial than other modalities. 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.