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

Summary Reviewer 1 
 
A 57-year-old female insured has requested reimbursement for a blood test performed on 
3/7/23. The Health Insurer has denied this request indicating that the service at issue was 
considered investigational for the evaluation of the insureds rheumatoid arthritis. The physician 
reviewer found that this patient presented with a history of rheumatoid arthritis, for which she 
underwent evaluation with a Vectra DA blood test. Scoring tools such as the Disease Activity 
Score 28 CRP (DAS 28-CRP), the Clinical Disease Activity Index (CDAI), and the Simplified Disease 
Activity Index (SDAI) are supported by the medical literature and routinely utilized for the 
assessment of rheumatoid arthritis disease activity in both clinical trials and in real clinical 
practice settings. There is a lack of medical literature or evidence suggesting that the Vectra DA 
test is more effective in establishing the level of rheumatoid arthritis disease activity experienced 
by a patient than the standard therapies noted above. For these reasons, the blood test 
performed on 3/7/23 was not likely to have been more beneficial for the evaluation of the 
patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 




A 22-year-old female enrollee has requested authorization and coverage for Botox injections. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees lymphatic malformation. The physician reviewer found botox injections have been established as medically necessary for treatment of the patients medical condition. The application of Botox to the healthy side of the face in patients with long-standing facial paralysis has been shown to be a minimally invasive technique that improves facial symmetry at rest and during facial motion. In addition, since this patient developed facial paralysis after treatment for a lymphatic malformation, surgery to treat the facial asymmetry would be considered reconstructive. Moreover, treatment with Botox should be considered medically necessary to improve the patients facial asymmetry. All told, Botox injections are medically necessary for treatment of the patients medical condition.  Therefore, the requested service is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 40-year-old female enrollee has requested authorization and coverage for breast reduction surgery. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee, who reported back, neck and shoulder pain. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. Symptomatic macromastia is a mechanical problem, and conservative treatments have been shown to be ineffective for this condition. Nonoperative treatments are unlikely to improve her pain. This patient has large pendulous breasts with shoulder grooving and the classic symptoms for macromastia. Breast reduction is the only treatment that is proven in the medical literature to be curative for symptomatic macromastia, and the peer-reviewed literature confirms the benefit of breast reduction surgery for women with upper torso pain due to breast hypertrophy. Thus, breast reduction surgery is medically necessary for the treatment of this patient. Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 65-year-old male has requested reimbursement for gene testing performed on 12/09/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found the most important decision for a patient with prostate cancer is whether to undergo specific cancer treatment, or to pursue active surveillance only.  Currently, such a decision often depends on the classification of that mans cancer as to risk of progression. Using this patients pathologic parameters and prostate specific antigen, he would be seen as falling into a low-risk group.  Such a patient would seriously consider surveillance only, with no specific cancer treatment.  Beyond these clinical features, a variety of genomic assays of the individuals cancer cells have been developed, amongst which is the 17 gene assay, Oncotype DX prostate cancer testing.  The medical evidence indicates that such assays are of value in patients with low risk cancer.  Thus, gene testing performed on 12/09/15 was likely to have been more effective than other methods of evaluating this patient.  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 3


A 42-year-old female has requested reimbursement for Anser IFX Assay testing performed on 10/26/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the Anser IFX Assay testing was ordered to determine the cause for possible reaction to and loss of response to Remicade.  The use of Anser IFX Assay testing to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials.  The presence of antibodies alone does not necessarily result in reaction to or loss of response to infliximab, nor have threshold drug levels been established. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Based on the clinical literature, the services at issue were not likely to have been superior over 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 2

A 71-year-old male enrollee has requested reimbursement ablation of the prostate, transrectal high intensity focused ultrasound (HIFU) including imaging guidance performed on 12/20/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee who has a history of prostate cancer. The physician reviewer found that the patient is a 71-year-old male with a history of prostate cancer (Gleason 7, T2c). He had high intensity focused ultrasound (HIFU) and had a rising prostate specific antigen (PSA). The patient has requested reimbursement for ablation of the prostate using transrectal HIFU including imaging guidance performed on 12/20/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for the treatment of the patient who has a history of prostate cancer. HIFU has been increasingly used for treatment of localized prostate cancer within the last decade. It has the theoretical potential of decreasing gastrointestinal, genitourinary and sexual toxicity. Potential candidates are patients with low to moderate risk prostate cancer. However, the available literature mainly consists of prospective case series and retrospective studies from Europe showing short to intermediate term outcomes for localized prostate cancer. As such, there is a lack of controlled trials available for analysis and very little long term survival data available. Additionally, there is a lack of validated biochemical and surrogate end point for cure. The National Comprehensive Cancer Network guidelines on prostate cancer state the following about focal therapy and HIFU, Other emerging local therapies, such as high intensity focused ultrasound (HIFU) and vascular-targeted photodynamic (VTP) also warrant further study. American Urological Association/American Society for Radiation Oncology/Society of Urologic Oncology guidelines note clinicians should inform low-risk prostate cancer patients who are considering focal therapy or high-intensity focused ultrasound (HIFU) that these interventions are not standard care options because comparative outcome evidence is lacking. Accordingly, the long term efficacy of the services at issue has not been established in this clinical setting. All told, transrectal HIFU including imaging guidance performed on 12/20/17 was not likely to have been more effective than other treatment options available for evaluating this patients medical condition. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 57-year-old female enrollee has requested reimbursement for comprehensive cancer genomic panel provided on 5/9/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees rectal carcinoma. The physician reviewer found that patients with refractory or relapsed cancer that have exhausted standard treatments are usually considered for clinical trials. Recently, it has become important to identify mutations that may be amenable to targeted therapy. One study of 86 patients reported that progression free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen (Von Hoff, et al). The regimen selected by molecular profiling offered a 27% survival advantage. Given this support, the comprehensive cancer genomic panel provided on 5/9/17 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 54-year-old female enrollee has requested authorization and coverage for Xyzal 5 mg two tablets per day. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees allergies and sleep difficulties. The physician reviewer found that the Xyzal is a second generation piperazine derivative oral anti-histamine. Xyzal is U.S. Food and Drug Administration (FDA) approved for the treatment of allergic rhinitis, seasonal allergic rhinitis orally at 2.5 or 5 mg once daily. Higher doses are approved for the treatment of chronic idiopathic urticarial. Oral antihistamines are typically second-line therapy for allergic rhinitis after intranasal corticosteroids (Wallace, et al). The patient states that she has used Zyrtec in the past but it stopped working. However, there is a lack of data that pharmacologic tolerance develops to antihistamines (Simons). Also, there is a paucity of evidence that doses of second-generation antihistamines greater than those maximally recommended increase efficacy for allergic rhinitis (Hansen). Although the patient states that the increased dose of Xyzal has helped her sleeping, this is not an FDA approved indication and would not be considered an extenuating circumstance. In this case, there is a lack of evidence of primary therapies being implemented and failed such as avoidance measures and intranasal corticosteroids (Wallace, et al). As such, the request for Xyzal 5 mg two tablets per day is not medically necessary. Based on the foregoing discussion, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 38-year-old female enrollee has requested authorization and coverage for rituximab infusions at UCSF Medical Center. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees rheumatoid arthritis. The physician reviewer found there are multiple studies demonstrating safety for long-term use of rituximab in this clinical setting. However, the risk of infusion reactions occur within 30-120 minutes of infusion and occur in 30-45% of patients. To prevent reactions, there are pretreatment medications which are recommended. Reactions may require aggressive treatments to include treatment of anaphylactic symptoms. It is therefore recommended that the patient continues to receive the rituximab infusions at the UCSF Medical Center. Therefore, the requested rituximab infusions at UCSF Medical Center are supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 60-year-old male enrollee has requested authorization and coverage for verapamil. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for verapamil injections in this clinical setting. The records document erectile dysfunction secondary to Peyronies plaque formation. He has difficulty maintaining erections and was diagnosed with plaque related erectile issue due to 15 degree lateral curvature. The medical evidence does not support an overall benefit of the use of this medication in terms of erectile outcomes, and the literature has noted minimal benefit to verapamil on lesion size reduction. This patients in-office response to Trimix suggests that his erectile function is intact and curvature is mild. Per the records, the patient may benefit from more standard therapies, inclusive of ultrasound and vacuum devices, to assist with mild curvature. Thus, verapamil is not likely to be of greater benefit than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 45-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 2/6/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the patient is a 45-year-old female with a family history of breast cancer. The patient had a screening mammogram including tomosynthesis performed on 2/6/15 revealing extremely dense tissue but no evidence of malignancy. The patient is requesting reimbursement for the breast tomosynthesis performed on 2/6/15. The Health Insurer has denied this request as investigational. The American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category in light of the advantages it brings to radiologists in the interpretation of mammograms particularly in cases of extremely dense tissue, such as in this case. The tomographic qualities of tomosynthesis often allow radiologists to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. Thus, the use of tomosynthesis was likely of more benefit to the patient than if she had her study using two-dimensional technique only. 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 3

A 52-year-old male enrollee has requested authorization and coverage for olaparib (Lynparza) tablet 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that this patient has exhausted several prior lines of therapy. The PARP inhibitor Lynparza was studied in 49 patients with castration resistant prostate cancer (Mateo, et al). In this phase II study, all patients were previously treated with at least two prior regimens for castration resistant disease and all had received prior docetaxel chemotherapy. Among the patients with a DNA repair gene abnormality, 88% demonstrated a response. Given this support, the requested Lynparza tablet 100 mg 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 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 2


A 31-year-old female enrollee has requested authorization and coverage for rituximab injection therapy. The Health Insurer has denied this request indicating that the requested therapy is considered investigational for treatment of the enrollees multiple sclerosis, relapsing-remitting. The physician reviewer found the current medical evidence does not support the superior efficacy of rituximab injection therapy for treatment of the patients medical condition. The use of rituximab in the treatment of relapsing remitting multiple sclerosis has not been demonstrated in randomized studies to have effectiveness in the treatment of multiple sclerosis relative to disability progression.  The Cochrane database representing a meta-analysis review has concluded that there is no demonstration of efficacy of this treatment. Based upon the information set forth above, the requested therapy is not likely to be effective 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 36-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 12/16/18. 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 Polymerase chain reaction testing has been compared to traditional clinical testing for vaginitis. The literature supports the use of polymerase chain reaction testing because it resulted in significantly higher sensitivity and negative predictive value than clinician diagnosis or in clinic testing. Schwebke and colleagues noted that polymerase chain reaction testing showed a statistically higher overall percent agreement with each of the reference methods than did clinician diagnosis or clinic testing. The authors noted that the test was also superior for detecting more than one cause for vaginitis. Polymerase chain reaction testing is commonly used in clinical practice. In sum, polymerase chain reaction testing performed on 12/16/18 was likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
 
A 49-year-old male enrollee has requested authorization and coverage for 0424T insertion 
neurostimulator system for central sleep apnea. The Health Insurer has denied this request and 
reported that the requested service is investigational for the treatment of the enrollees central 
sleep apnea. The physician reviewer found that Ding and Zhang note that transvenous phrenic 
nerve stimulation is an effective and safe therapeutic approach that is approved by the FDA for 
the treatment of moderate to severe central apnea. In this case, notes dated 6/18/22 reported a 
sleep study dated 12/18/18 reported 27 obstructive apneas, 70 central apneas, zero mixed 
apneas, and 85 hypopneas. The patient has failed ASV and other PAP therapy modalities and has 
symptomatic central apnea. Given that the patient has failed first-line of treatment of central 
apnea with ASV and PAP therapy, phrenic nerve stimulation is likely to be more beneficial in this 
case than standard therapies. Therefore, 0424T insertion neurostimulator system for central 
sleep apnea 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 46-year-old female enrollee has requested authorization and coverage for endovenous ablation therapy of the right SSV. 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 current medical evidence supports the requested services in this clinical setting. The Health Insurers denial was based upon the size of the small saphenous vein that will be the target of treatment. Per the records, the vein has reflux. Although increasing saphenous vein size does correlate with severity of vein disease, patients with C2-C3 disease still have been reported to have small saphenous veins measuring as small as 2.4 mm at the junction (mean of 4.3 mm). In order to determine the medical necessity of the treatment, the total clinical picture must be evaluated. In this patients case, she is likely to benefit from the requested services. Therefore, endovenous ablation therapy of the right small saphenous vein is medically necessary for the treatment of this patient.