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

Summary Reviewer 2


A 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found the current medical evidence has not established the superior efficacy of the services at issue.  Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment.  The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  However, while there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  All told, Anser IFX testing performed on 8/17/15 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: Experimental
Decision: Overturned

Summary Reviewer 1

The parent of a four-year-old male enrollee has requested reimbursement for chromosomal microarray testing provided on 11/12/18. 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 clinical utility of chromosomal microarray (CMA) is well-established, and is now considered first-line genetic testing for individuals with developmental delays and autism spectrum disorders. It is important to note that CMA technology has been shown to provide clinically actionable information. Research continues to support the use of CMA testing in the evaluation of developmental delays and autism spectrum disorders. Recent evidence-based international guidelines promote the use of CMA as a first-tier investigation for global developmental delay if no etiological indicators from history and examination are found. The higher sensitivity that it has for identifying submicroscopic deletions and duplications (than standard karyotyping methods) and better definition of the breakpoints and size of imbalances all make CMA a suitable first-line test. Therefore, chromosomal microarray testing provided on 11/12/18 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer

The patient is a 27-year-old male who presented with complaints of difficulty concentrating. The patient was referred to the neuropsychology service on 9/6/17 by his primary care provider. The patient has requested reimbursement for neuropsychological testing provided from 9/20/17 through 10/4/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. From the clinical perspective, according to the American Academy of Clinical Neuropsychology, the decision to order neuropsychological testing for an individual patient remains a matter of clinical judgment. However, the medical records do not include objective observations such as a mental status evaluation, physical examination or validated rating scales like the Folstein Mini-Mental State Examination or Montreal Cognitive Assessment. There was no report of learning disorder, neurological disease, abrupt personality change, bizarre behavior or memory decline. It does not appear that the patient had engaged in treatment or lifestyle modification to address the inattention. The patients siblings were reportedly diagnosed with attention deficit hyperactivity disorder (ADHD). However, neuropsychological testing is not needed to establish the diagnosis of ADHD. Thus, the neuropsychological testing provided from 9/20/17 through 10/4/17 was not medically necessary for evaluation of the patients medical condition. Based on the foregoing discussion, 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: Upheld

Summary Reviewer 1

A 47-year-old male enrollee has requested reimbursement for the Oncotype Dx Colon Cancer Assay provided on 2/14/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees rectosigmoid cancer. The physician reviewer found that in the peer-reviewed medical literature, there is adequate data demonstrating the benefit from adjuvant chemotherapy in patients with stage III colon cancer. However, it remains controversial whether adjuvant chemotherapy has a role in treating patients with stage II colon cancer. Currently, the decision to treat with adjuvant chemotherapy focuses on the specific features of the cancer such as high grade pathology, lymphovascular invasion, or the presence of obstruction or perforation. In this patients case, none of these features were present. The Oncotype DX Colon Cancer Assay is a 12-gene panel that aims to help predict the risk of recurrence in stage II patients and guide the need for adjuvant chemotherapy. However, there is a paucity of support in the clinical studies showing that use of the Oncotype DX results in superior health outcomes when compared to the standard of care. For these reasons, the Oncotype DX Colon Cancer Assay provided on 2/14/18 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 30-year-old female enrollee has requested reimbursement for bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient had a history of bilateral hallux valgus deformities, and she underwent surgery for correction of this painful deformity. The provider elected to perform the modified McBride procedure combined with a chevron osteotomy of the left great toe on 6/10/19 and a modified McBride procedure combined with a scarf osteotomy of the right great toe on 7/29/19. Fluoroscopy was utilized for both surgical procedures. Hallux valgus deformity is a common chronic problem, and its chief complaint is pain. The procedures performed, including the modified McBride, chevron osteotomy, and scarf osteotomy, are all current procedures with documented good results. There is sufficient support for the services at issue in this clinical setting. Thus, bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19 was likely to have been more beneficial than other treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 38-year-old female has requested reimbursement for fecal calprotectin testing performed on 11/22/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative pan-colitis. The physician reviewer found that the use of fecal calprotectin is supported for management of patients with ulcerative colitis to prevent invasive interventions such as colonoscopy. A randomized, prospective, controlled trial by Lasson and colleagues evaluating patients with ulcerative colitis showed lower relapse rate than control when using calprotectin to direct management with medications. Another prospective study by Costa and colleagues showed that unlike in Crohns disease, fecal calprotectin was sensitive and specific for prediction of relapse in ulcerative colitis, making it a useful tool for non-invasive monitoring. In this patients case, the test allowed for assessment of ulcerative colitis disease activity without colonoscopy. For these reasons, fecal calprotectin testing performed on 11/22/17 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 58-year-old male enrollee has requested authorization and coverage for endovenous laser therapy procedure. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who is diagnosed with venous insufficiency. The physician reviewer found that the 58-year-old male enrollee has requested authorization and coverage for endovenous laser therapy procedure. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who is diagnosed with venous insufficiency.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 61-year-old female enrollee has requested reimbursement for the office visits provided on 5/20/16, 8/25/16, and 11/17/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees hypothyroidism, Hashimotos thyroiditis, menopause syndrome, and iron deficiency anemia. The physician reviewer found that the records document that the office visit on 5/20/16 was indicated to follow the patients thyroid levels. However, there is a lack of evidence supporting follow-up office visits on 8/25/16 and 11/17/16. Although it is important to follow thyroid stimulating hormone (TSH) and free T4 in patients on LT4 and T3, it is unclear why these need to be checked every three months for this patient. Given these findings, the office visit on 5/20/16 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, while the office visits on 8/25/16 and 11/17/16 were 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, a portion of 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 partially overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 58-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma (laboratory service code 84999) rendered on 8/25/17.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma.

. The physician reviewer found that this patient is a 58-year-old male with a history of malignant melanoma of 0.51 mm Breslow depth on the left anterior shoulder. The provider recommended gene testing to assess the metastatic risk of the tumor. The patient has requested reimbursement for DecisionDx-Melanoma (laboratory service code 84999) rendered on 8/25/17.  The Health Insurer denied this request and reported that the services at issue were considered investigational for evaluating this patients medical condition. The use of this type of testing is not considered to be a standard of care in the evaluation of assessing a patients melanoma. The National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting. As such, the utilization of DecisionDx-Melanoma gene assay cannot be expected to affect the treatment or health outcome of this patients melanoma. Therefore, DecisionDx-Melanoma (laboratory service code 84999) rendered on 8/25/17 was not likely to have been more effective for the evaluation of this patients medical condition than any available standard therapy. Therefore, for the reasons stated above, the services at issue were not likely to have been 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 75-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 5/26/21. 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 Melanoma is a cancer that is curable in its earliest stages. Cutaneous 
melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for 
those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be 
amenable to excision but this suggests a high risk for the development of metastatic disease in 
the future. Such patients may be observed or treated with interferon-alpha. The data on 
DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node 
biopsy. There has also been some lack of consistency between various genes being used as 
biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the 
treatment algorithm beyond standard staging techniques. This is also the consensus opinion of 
the  National  Comprehensive  Cancer  Network  guidelines.  Therefore,  DecisionDx-Melanoma 
testing performed on 5/26/21 was not likely to have been more beneficial than any available 
standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 25-year-old male enrollee has requested reimbursement for quantitative EEG (brain mapping) performed from 7/02/20 through 8/25/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeAaas medical condition. The physician reviewer found that the patient has history of major depressive disorder with suicidal ideations. He has been previously hospitalized for psychiatric care for the same. The patient has already received traditional care for this diagnosis. There is evidence that quantitative EEG can have findings which can be used a biomarker for suicidality. EEG activity in theta band has clinical potential as a biomarker for preventing suicide. Furthermore, high-gamma rhythm has the potential to be used as a biomarker for screening suicidality. The use of quantitative EEG findings can be used to treat patients with neurofeedback. Therefore, quantitative EEG (brain mapping) performed from 7/02/20 through 8/25/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is a 28-year-old male who presented to his provider on 9/2/22. The patient has 
requested reimbursement for magnetic resonance (e.g. proton) imaging, any joint of lower 
extremity, without contrast material, on 9/21/22. The Health insurer has denied this request and 
reported that the services at issue were not medically necessary for the evaluation of this patient.  
The physician reviewer found that the submitted documentation supports the medical necessity 
of a portion of the services at issue. In this case, the patient had left ankle and right knee pain for 
years that did not respond to conservative treatment. Notes dated 9/2/22 reported left posterior 
tibial tendon tenderness and a positive Tinels sign, suggesting impingement. Subsequent MRI 
imaging of the ankle did not show structural issues. The patient reported that the MRIs resulted 
in a diagnosis of Tarsal Tunnel syndrome and referral for EMG. An EMG was conducted by a 
neurologist that confirmed the diagnosis. Notes dated 9/2/22 also reported severe right knee 
medial joint line tenderness and patellofemoral pain. MRI of the right knee revealed a deep root 
tear of the meniscus requiring arthroscopy. While the American College of Radiology (ACR) notes 
that MRI is usually not appropriate in the setting of chronic ankle or knee pain without prior x-
rays, given this patients multi-year history of prolonged and unexplained ankle and knee pain, 
the services at issue were medically indicated. Therefore, magnetic resonance imaging of the 
right knee and the left ankle were medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 69-year-old female enrollee has requested authorization and coverage for Prolia 60 mg/mL syringe. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that Osteoporosis is an increasingly widespread condition.  Fractures are the most dangerous aspect of osteoporosis, and this can lead to acute and chronic pain as well as increased mortality. While bisphosphonate therapy has been available for the treatment of osteoporosis for a number of years, a newer medication, denosumab (Prolia) is a fully human monoclonal antibody that has been approved for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone. Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapy. While both bisphosphonates and Prolia have been shown to be effective at improving bone mineral density and reducing the risk of subsequent fractures, recent data suggests that Prolia has superior efficacy, particularly in the region of the spine.  Because this patient has severe osteoporosis, with lowest bone mineral density in the region of the spine, and has sustained a fracture in the past, Prolia is medically indicated. Therefore, Prolia 60 mg/mL syringe is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 67-year-old male with medical history of gastroesophageal reflux disease (GERD), hyperlipidemia, and hernia repair.  The patient has requested reimbursement for inpatient hospital stay provided from 6/18/21 through 6/20/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the inpatient level of care is not supported based on the submitted documentation. The patient had abdominal pain, nausea, and vomiting, as well as imaging concerning for at least partial small bowel obstruction. However, CT scan of the abdomen and pelvis did not show pathology such as gastrointestinal perforation, abscess, or toxic megacolon. He had gradual advancement of diet, and was tolerating a full liquid diet by 6/20/21. Although uncomplicated small bowel obstruction may have been present, the patient did not have clinical gastrointestinal bleeding, peritonitis, sepsis, or other complications warranting inpatient level of care. The standard of care for uncomplicated small bowel obstruction was performed, including intravenous fluids and gradual advancement of diet, and all could have been performed without the inpatient level of care, at the observation level of care. The measures that were undertaken, including observation, monitoring, laboratory testing, imaging, and advancement of diet, could have been performed without the inpatient level of care. For these reasons, inpatient hospital stay provided from 6/18/21 through 6/20/21 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 61-year-old female enrollee has requested reimbursement for Nuvigil provided from 1/1/15 through 8/1/15. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees circadian rhythm disorder, shift work type. The physician reviewer found that Nuvigil has been provided to this patient for circadian rhythm disorder, shift work type. This medication has shown efficacy and has an indication for this condition (Czeisler, et al; Morgenthaler, et al). However, this patients records do not support a diagnosis of shift work sleep disorder. Further, there is no reference to any other condition such as narcolepsy or treated obstructive sleep apnea which may support an indication for Nuvigil. Given this lack of information, the Nuvigil provided to this patient from 1/1/15 through 8/1/15 was not medically necessary.  Consistent with these findings, the medication at issue was 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 

The patient is a 48-year-old female who has been diagnosed with atopic dermatitis of the face. She has failed therapy with topical triamcinolone. The patient has requested authorization and coverage for Dupixent prefilled syringe 300 mg/2 ml. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that Dupixent has been approved by the U.S. Food and Drug Administration for the treatment of adult patients with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies. There are very few treatments approved for this condition, and this  drug has quickly become a standard/preferred therapeutic option by dermatologists in the community. The data supporting its use in moderate-to-severe atopic dermatitis is substantial, and it has a favorable side effect profile in comparison to other systemic agents that would be available to this patient. Based on the submitted documentation, the patient appears to be a good candidate for this treatment. Therefore, Dupixent prefilled syringe 300 mg/2 ml is medically necessary for the treatment of this patient.