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

Summary Reviewer 3


A 62-year-old male enrollee has requested reimbursement for the Life Vest provided from 6/10/15 through 7/10/15. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees dilated cardiomyopathy. The physician reviewer found that review of the current peer-reviewed medical literature does not support wearable cardioverter defibrillators as being proven to demonstrate survival benefit above and beyond medical therapy. Adler and colleagues noted that when the prescription of a wearable defibrillator is being considered, it should be kept in mind that there are no randomized controlled studies showing that provides survival benefit. Further, wearable cardioverter defibrillators are currently indicated for patients who are candidates for an implantable cardioverter defibrillator and are awaiting cardiac transplantation, patients who are candidates for an implantable cardioverter defibrillator and have a temporary contraindication to implantable cardioverter defibrillator implant, and patients who have had an implantable cardioverter defibrillator explanted due to infection and are awaiting re-implantation. As this patient does not meet these criteria, the Life Vest provided from 6/10/15 through 7/10/15 was 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, I have determined the device at issue was 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 48-year-old female has requested reimbursement for genotyping for CYP2D6 polymorphism performed on 7/10/14.  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 since tamoxifen must be metabolized to a metabolite to be active, there has been an interest in evaluating the impact of the enzymes that affect this metabolism to an active state.  CYP2D6 is involved in the conversion of tamoxifen to endoxifen, its most active metabolite.  There have been multiple studies attempting to correlate CYP2D6 genotype to the efficacy of tamoxifen.  The overall conclusion is that there is no clear-cut benefit to the use of this genotyping in determining whether tamoxifen should be given to an individual patient.  There is insufficient data in either premenopausal or postmenopausal women to establish that CYP2D6 genotyping would be beneficial.  Therefore, genotyping for CYP2D6 polymorphism performed on 7/10/14 was not likely to have been of greater benefit than other methods of evaluation.  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 46-year-old female enrollee has requested reimbursement for Afirma Gene Expression Classifier testing performed on 9/6/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees thyroid nodule. The physician reviewer found that according to Alexander and colleagues Patients with cytologically indeterminate nodules are often referred for diagnostic surgery, though most of these nodules prove to be benign. Gene expression classifiers better distinguish benign from malignant thyroid nodules. In this case, the patients initial cytology was indeterminate for surgery and the Afirma genetic test is a useful tool when cytology is indeterminate. Accordingly, the specimen sent for Afirma gene expression classifier performed on 9/6/16 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a 16-year-old transgender male enrollee has requested reimbursement for bilateral mastectomy performed on 6/20/18. The Health Insurer has denied this request indicating that the procedure at issue was not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found that the submitted documentation supports the medical necessity of the procedure at issue. This patient had a mental health assessment from a qualified mental health provider. He meets World Professional Association for Transgender Health (WPATH) criteria for chest surgery as a medically necessary treatment for gender dysphoria. The patients age being under 18 does not affect the medical necessity of the procedure. WPATH states that chest surgery for transgender male adolescents may be done under 18. One year of hormone treatment and social transition is suggested, but not required. Per the records, this patient had met these suggestions for hormone treatment and social transition. The current medical evidence supports the procedure at issue in this clinical setting. Thus, bilateral mastectomy performed on 6/20/18 was medically necessary for the treatment of this patient. Therefore, the procedure at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The parent of a 15-year-old female enrollee has requested reimbursement for Prometheus Anser ADA testing performed on 10/10/17. 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 there is sufficient support for the services at issue in this clinical setting. During the several months prior to the testing, the patient experienced nausea, low energy and feeling of being unwell with normal gastrointestinal symptoms. Scientific studies have suggested that drug levels and antibody testing for adalimumab is now a standard method to determine disease response to treatment. The studies also suggest that higher levels of adalimumab are associated with better therapeutic outcomes and biologic remission. In this case, the patient was having symptoms which were suggestive of relapse. Thus, it was appropriate for adalimumab levels and antibodies to be measured to determine the next steps in the management of the patients symptoms. 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: Upheld

Summary Reviewer 2


A 53-year-old female has requested reimbursement for advanced lipoprotein testing.  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 the medical records fail to establish the superior efficacy of the services at issue.  There is a lack of accepted studies which demonstrate that strategies to correct the residual risk potentially identified by novel lipoprotein will further reduce cardiovascular risk.  It is not clear that advanced lipoprotein testing adds significant information to what is already known from a fasting lipid panel.  There is insufficient evidence to support the use of advanced lipoprotein analysis in clinical practice.  In sum, advanced lipoprotein testing performed on 3/15/16 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 20-year-old female who has been diagnosed with a maxillofacial skeletal deformity. The patient has requested authorization and coverage for reconstruction midface, LeFort 1; three or more pieces, segment movement in any direction, without bone graft (21143) and reconstruction of mandibular rami, horizontal, vertical, C or L osteotomy, with bone graft (includes obtaining graft) (21194). 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 submitted documentation supports the medical necessity of the requested services. The patient has a maxillofacial skeletal deformity that cannot be corrected with orthodontics alone. The requested surgery will result in improved musculoskeletal and dento-osseous relationships and improvement in mastication and associated temporomandibular joint and associated muscular disorders. The requested procedure is medically appropriate for the treatment of this patientas  condition and is within generally accepted standards of medical care. Therefore, reconstruction midface, LeFort 1; three or more pieces, segment movement in any direction, without bone graft (21143) and reconstruction of mandibular rami, horizontal, vertical, C or L osteotomy, with bone graft (includes obtaining graft) (21194) are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 23-year-old female enrollee has requested reimbursement for continued stay at partial hospital substance use disorders treatment provided from 9/27/17 through 10/01/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The progress notes indicated that the patient was cooperative in treatment. The progress notes for the disputed timeframe indicate that the patient was attentive during group discussions and was engaged in therapy discussions. Per the records, this patient could have received effective treatment on an intensive outpatient basis or outpatient basis. She was motivated for treatment with mention of insight into her illness as well as documentation of her knowledge of skills to maintain sobriety. The supplied documentation does not indicate that she was having severe mood swings or other severe psychiatric symptoms. In cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. With regards to risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. In terms of functional status, the records support a score of 2 or 3 due to the loss of her job prior to treatment and continued substance use. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability. In terms of level of stress of the recovery environment, the records support a score of 3. There was mention of being homeless on admission due to substance use. With regards to level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources. In terms of treatment and recovery history, the records support a score of 3. The treatment progress notes indicate that she had good progress and participation in her partial hospitalization program treatment. With regards to engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into her need for treatment. Thus, the patient has a composite score of 15 or 16. This score correlates with the community-based outpatient clinic setting. In sum, the patient could have been treated in a less restrictive setting. All told, continued stay at partial hospital substance use disorders treatment provided from 9/27/17 through 10/01/17 was not medically necessary for the treatment of this patient. 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 28-year-old male enrollee has requested reimbursement for cyanocobalamin (vitamin B-12) testing performed on 7/24/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that Vitamin B12 deficiency is considered as a possible problem for patients who have associated anemia, gastrointestinal issues (which may lead to poor absorption) or neuropsychiatric problems, including irritability or cognitive decline with nerve problems. Typically, the evaluation includes a history and physical examination with abnormal dermatologic, neurologic or gastrointestinal problems. The laboratory evaluation includes B12, folate levels and a complete blood count. In this case, the documentation does not support that the patient had medical conditions or symptoms that would be consistent with vitamin B12 deficiency. Furthermore, there was no laboratory testing to include a folate level or complete blood count. Therefore, cyanocobalamin (vitamin B-12) testing performed on 7/24/19 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 72-year-old male enrollee has requested reimbursement for Oncotype DX Prostate Cancer Assay performed on 4/21/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for evaluation of the enrollees prostate cancer. The physician reviewer found there currently are three major approaches to the management of localized prostate cancer. These include surgical prostatectomy, radiation therapy, and active surveillance.  Recommendations are made as to these options based on risk stratification, which estimates the risk for the future development of progressive cancer. The patients cancer is evaluated with a combination of clinical features, prostate-specific antigen, and pathologic details, particularly Gleason cancer grade.  By such a method, patients can be placed into four general categories: very low risk, low risk, intermediate risk, and high risk. Therapeutic recommendations will then depend on this risk classification. By this methodology, this patient would be classified as very low risk, for whom surveillance only would be the recommendation. A further refinement of prognostication is the use of gene panels, such as Oncotype DX Prostate Cancer Assay. This is a panel of 17 genes that may assist in predicting recurrence after treatment for prostate cancer. It is being used to some degree in localized cancer as a possible aid in decision making. However, in this setting of a very low risk patient, it has not been clinically validated as ultimately clinically beneficial. In this patients case, the services at issue were not medically indicated given his very low risk cancer. Thus, Oncotype DX Prostate Cancer Assay performed on 4/21/17 was not medically necessary for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 60-year-old female enrollee has requested reimbursement for gene tests performed on 6/09/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees non-small cell lung cancer. The physician reviewer found that for patients with adenocarcinoma, there is clinical value in testing the tissue for certain mutations. In this patients case, apparently her liver biopsy was positive for an epidermal growth factor receptor (EGFR) exon 19 mutation. Therefore, this indicated that Tarceva might be useful. When patients on Tarceva progress, it is valuable to test for a further EGFR mutation (T790M) by a blood test, such as Guardant. If this new mutation is present, there is a treatment directed at that (Tagrisso). However, testing for a wide variety of other mutations is currently not clinically beneficial, as it has not been demonstrated that giving a treatment directed at a target found in that way is an improvement over giving a treatment based on the clinicians judgment. Finding a mutation does not guarantee that a drug directed at that target will be efficacious. All told, testing for T790M alone was likely to have been more efficacious than other methods of evaluating this patient. However, the superior efficacy of the remaining of the services at issue has not been established. Based upon the information set forth above, a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 59-year-old female enrollee has requested reimbursement for CPT codes 81201-90, 81210-90, 81211-90, 81282-90, 81295-90 and 81298-90 provided on 2/19/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees 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 but is not yet ready for routine clinical use. Although the ability to decipher genomic aberrations in individual breast cancers to the single nucleotide resolution is now possible, there is a lack of data to show that this information can guide treatment decisions for patients with metastatic breast cancer. The use of next generation sequencing, such as with FoundationOne testing, continues to be the subject of ongoing clinical trials. Therefore, CPT codes 81201 and 81210 provided on 2/19/18 were not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
 
A 30-year-old female enrollee has requested authorization and coverage for Xeljanz 5 mg tablet. 
The Health Insurer has denied this request and reported that the requested medication is 
investigational for the treatment of the enrollees medical condition. The physician reviewer 
found that there is no currently FDA approved treatment for alopecia areata, totalis, and similar 
alopecias.  Thus,  there  is  no  standard  approved  treatment.  Baricitinib  (Janus  kinase  (JAK) 
inhibitor) has done well in phase 2 clinical trials and may be soon approved. This patients 
provider is requesting another JAK inhibitor, tofacitinib. In addition, per clinical notes from the 
patients dermatologist, the patient has tried and failed other treatments, including topical 
steroids and oral minoxidil. Notably, the patient has done well on Xeljanz since March 2021, with 
near total regrowth of hair. There are several large case series reports in the literature of 
improvement of alopecia with tofacitinib. Thus, there is a large body of growing evidence that 
JAK inhibitors, in particular tofacitinib, is efficacious for alopecia areata/totalis. Therefore, Xeljanz 
5 mg tablet is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A year-old female enrollee has requested reimbursement for collagen crosslink testing provided on 4/17/19. 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 Osteoporosis is a condition of thinning of the bones that leads to an increased risk of fracture.  It  is defined by the World Health Organization (WHO) as a bone mineral density of 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults), as measured by dual-energy x-ray absorptiometry (DEXA). Bone mineral density assessment via DEXA is still the criterion standard for evaluation and diagnosis of osteoporosis. However, because changes in bone mass and density in response to antiresorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover may be a useful adjunct in monitoring of osteoporotic patients treated with antiresorptive agents. Medical evidence suggests that biochemical markers could be useful in making therapeutic decisions because, in general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine. There is sufficient support for the services at issue in this clinical setting. Therefore, collagen crosslink testing provided on 4/17/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 53-year-old female enrollee has requested reimbursement for PathFinder TG testing (84999) performed on 7/30/14.  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 current Guidelines from the American Gastroenterological Association Institute do not mention the use of molecular markers for the management of suspicious pancreatic cysts. A recently published technical review by the American Gastroenterological Association of the diagnosis of pancreatic cysts states that routine use cannot be supported at this time.  At this time, although molecular testing is encouraging, further validation is needed.  All told, PathFinder TG testing (84999) performed on 7/30/14 was not likely to have been of greater benefit than other modalities.  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.