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

Summary Reviewer 3


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 in this case, the patient has Crohns disease and failed treatment with Cimzia and was switched to Humira. The patient had a better response to a higher dose. Hence, there was consideration for Humira failure or development of antibodies and consideration was being entertained to potentially switch to yet another biologic versus maintenance on a higher dose of Humira. To better guide the management, an ADA test was performed. Due to the multitude of management options once a patient has no response to Humira and the fact that Humira has a wide array of adverse effects, it is important for the treating provider to have a roadmap of the nature of the patients clinical course. ADA testing provides important and significant management implications, and was clinically indicated in this case given the suspicion for potential antibodies or lack of response. 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 23-year-old female enrollee has requested reimbursement for inpatient hospital stay from 9/06/18 through 9/08/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient did not meet criteria for acute inpatient admission. She could have been safely and effectively managed under an observational level of care. Patients with uncontrolled diabetes with nausea, vomiting and blood sugars in the 300s do require observation to control blood sugars.  However, acute inpatient admission is required when there is evidence of severe acidosis, evidence of end organ damage, persistent symptoms, electrolyte disturbances or altered mental status. There is no clinical evidence to support the patient meeting any of these requirements. Furthermore, there was no evidence of fetal distress or maternal hemodynamic instability to support acute inpatient admission. Therefore, inpatient hospital stay from 9/06/18 through 9/08/18 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 63-year-old male enrollee has requested reimbursement for the Foundation One test performed on 3/13/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees metastatic poorly differentiated carcinoma. The physician reviewer found that the utility of the Foundation One testing has not been demonstrated to improve patient outcomes as compared to standard testing. According to the National Comprehensive Cancer Network (NCCN), to demonstrate clinical utility of panel genetic testing such as Foundation One, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. The available literature on clinical utility consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. This evidence is not sufficient to make conclusions on clinical utility. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the Foundation One test provided on 3/13/16 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: Upheld

Summary Reviewer 3

A 35-year-old female has requested reimbursement for Oncotype Dx Colon Cancer Assay provided on 11/16/18. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that in this patients case, a tumor sample was submitted for Oncotype DX Colon Cancer Assay testing to help decide adjuvant chemotherapy. The Oncotype DX Colon Cancer Assay uses a reverse transcriptase-polymerase chain reaction assay for 12 genes in an algorithm that can be used to predict recurrence. The medical evidence for the test is excellent and sufficient to allow its use to estimate the risk of recurrence for stage II patients. However, current data does not support its use as a predictive marker for response to adjuvant treatment. As such, the National Comprehensive Cancer Network guidelines noted there are insufficient data to recommend use of multi-gene assay panels to determine adjuvant therapy. Thus, Oncotype DX Colon Cancer Assay performed on 11/16/18 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 37-year-old female enrollee has requested reimbursement for gene testing performed on 1/19/15.  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 current medical evidence supports the services at issue in this clinical setting.  The advent of genetic testing and analysis has helped providers to better characterize the chances of malignancy and in this case suggested the need for surgery.  There is sufficient support for the services at issue in this patients case.  The services at issue provided information which aided in management.  Therefore, gene testing performed on 1/19/15 was likely to have been of greater benefit than other modalities.  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: Upheld

Summary Reviewer 

A 65-year-old female enrollee has requested authorization and coverage for spinal surgery (CPT codes 22212, 63048, 22610, 20931, 63046, 22840, 22842, 22853, 22845, 22556, 22216, 63077, and 22614) and five (5) inpatient days. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees back pain. The physician reviewer found that in the medical literature, Resnick and Groff noted that lumbar fusion is performed for the treatment of painful instability of the spine, usually manifest as chronic low back pain. The documentation available for review does not include evidence of any instability in the thoracic spine. Further, there is no severe stenosis or deformity. The medical records indicate that this patient underwent previous lumbar and cervical fusion surgeries and presents with 50 degrees of kyphosis in the mid-thoracic spine. However, 50 degrees of kyphosis is considered mild in the thoracic spine and does not support the need for fusion. (Chou, et al; Resnick). All told, the requested spinal surgery (CPT codes 22212, 63048, 22610, 20931, 63046, 22840, 22842, 22853, 22845, 22556, 22216, 63077, and 22614) and five (5) inpatient days is not supported as medically necessary for treatment of this patients back pain. Based on the foregoing discussion, he requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 62-year-old male enrollee has requested reimbursement for laboratory testing (Fibrotest-Actitest) performed on 8/14/15.  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 there is sufficient support for the services at issue in this clinical setting.  It is standard of care in contemporary gastroenterology to use when possible noninvasive testing as a measure of hepatic fibrosis.  Elastography is one such noninvasive technique whereby ultrasound imaging provides objective data to evaluate tissue elasticity or stiffness by measuring tissue displacement.  When liver biopsy is undesired, FibroScan demonstrates greater accuracy, sensitivity, and specificity for predicting and discriminating minimal or no fibrosis from extensive fibrosis.  FibroSure is more widely available than FibroScan, and represents a well-recognized community-standard approach to noninvasive assessment of hepatic fibrosis.  In this patients case, the current medical evidence supports the services at issue.  Thus, laboratory testing (Fibrotest-Actitest) performed on 8/14/15 was likely to have been more efficacious than other methods of evaluation.  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 61-year-old female has requested authorization and coverage for 64568, 0466T and 95970. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea.  The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. She has obstructive sleep apnea. The records noted prior use of CPAP. However, the records do not document attempts at helping the patient with tolerating the CPAP were exhausted. The clinical notes do not document that conservative treatment options have been exhausted, including oral appliance therapy. All told, the requested services (64568, 0466T and 95970) are not likely to be more effective than other treatment alternatives. 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 57-year-old female enrollee has requested reimbursement and prospective authorization and coverage for Opsumit provided from 4/22/15 forward. The Health Insurer has denied this request indicating that the medication at issue was not and is not medically necessary for treatment of the enrollees pulmonary arterial hypertension. The physician reviewer found Tracleer was the first endothelin receptor antagonist that was U.S. Food and Drug Administration (FDA) approved for the treatment of primary pulmonary hypertension. Letairis and Opsumit are other endothelin receptor antagonists that gained FDA approval in 2007 and 2013, respectively. Based on the FDA approvals, each of these medications has a similar profile and potential side effects. The FDA notes that each of the medications can cause liver damage and liver function has to be monitored. Each of these medications can cause fluid retention and are not to be used in patients with liver disease. However, there is a lack of data demonstrating that any of these three drugs is superior to the other two medications. Thus, the patients pulmonary arterial hypertension can be treated with either of the Health Insurers formulary medications, Tracleer or Letairis with equivalent efficacy. Therefore, the Opsumit provided from 4/22/15 forward was not and is not medically necessary for treatment of this patients pulmonary arterial hypertension.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 60-year-old female enrollee has requested reimbursement for Prolia (denosumab) injection administered on 10/20/15. The Health Insurer has denied this request indicating that the medication at issue is considered investigational for treatment of the enrollees osteoporosis.The physician reviewer found scienific studies reveal that osteoporosis is an increasingly widespread condition, affecting 55% of Americans aged 50 and above. Of these, approximately 80% are women.  Fractures are the most dangerous aspect of osteoporosis. They can lead to acute and chronic pain as well as increased mortality (Old and Calvert).  A newer medication, denosumab (Prolia) is a fully human monoclonal antibody which has been approved for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone (McClung, et al). Studies support the use of Prolia for the treatment of postmenopausal women with osteoporosis who are at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapies.  This patient met medical necessity criteria for Prolia, as she failed other anti-resportive therapies for her osteoporosis.  Therefore, the medication at issue was likely to be more efficacious in treatment of the patients osteoporosis than any available standard of therapy. Based upon the information set forth above, the medication at issue was 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 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 based on the submitted records, this patient presented with some coronary risk.  In this circumstance, primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  In sum, advanced lipoprotein testing performed on 3/15/16 was not likely to have been 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: Upheld

Summary Reviewer 1

A 62-year-old female enrollee has requested reimbursement for the DecisionDx melanoma gene expression assay provided on 7/29/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that this patient presents with a melanoma with a Breslows depth of 3.65 mm. This places her into at least stage 2 disease. In stage 2 disease the National Comprehensive Cancer Network (NCCN) guidelines dictate certain protocols for further diagnosis, staging and prognosis as well as treatment paradigms. The melanoma DecisionDx testing would not change the staging, guidelines or care of this patient. Therefore, the DecisionDx testing performed on 7/29/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


An 18-year-old male enrollee has requested reimbursement for psychiatric residential treatment provided from 11/05/12 through 12/06/12.  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 the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was admitted after having felt stressed at his boarding school.  He did not feel he could fit in and cut and scratched himself from the stress.  Per the medical records, he was cooperative in his treatment program.  He had an episode of scratching when he felt stressed at the thought of returning to his old school.  The patient was given a discharge diagnosis of major depressive disorder, in remission, and attention deficit/hyperactivity disorder.  These conditions could have been safely treated at a lower level of care.  It appears that removing him from the stress of the boarding school was a main factor in his improvement, and this could have been accomplished in a setting other than residential treatment.  His scratching and cutting appear to be more stress relief and do not appear to be specific attempts at suicide.  All told, psychiatric residential treatment provided from 11/05/12 through 12/06/12 was not medically indicated 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: Experimental
Decision: Overturned

Summary Reviewer 1

A 51-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) performed on 3/18/19. 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 per the medical evidence, PCR testing is appropriate and medically indicated when done to test for chlamydia, gonorrhea, and trichomonas. In this case, the patient did have gonorrhea and chlamydia PCR, and this was covered by the Health Insurer. However, multiple additional PCR
tests were done for various other vaginal organisms, some of which do not even cause infection. PCR testing for these organisms is not standard of care. Therefore, PCR testing performed on 3/18/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 28-year-old female enrollee has requested reimbursement for emergency services provided on 4/27/16. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found at issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. 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. Review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with a sunburn. She reported pruritis, but declined Benadryl. She denied fever, vomiting, headache, or weakness. The patients pain was rated at 5/10. No blistering of the skin was present. The patient denied any other systemic symptoms. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services provided on 4/27/16 did not meet prudent layperson criteria for emergency care.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 44-year-old female enrollee has requested reimbursement for an AmniSure test that was performed on 4/7/14. The Health Insurer has denied this request indicating that the test at issue is considered investigational for evaluation of the rupture of the fetal membrane. The physician reviewer found that AmniSure testing (placental alpha-microglobulin-1 measurement) is recommended as an adjunct to standard assessment of pooling, ferning and nitrazine testing of vaginal fluid when these tests are inconclusive. AmniSure is not recommended as a first line test. Studies examining the measurement of placental alpha-microglobulin-1 are mixed. While there is some data supporting the utility of the assay, others studies have noted false-positive rates of 1930% in patients with clinically intact membranes and symptoms of labor (ACOG Practice Bulletin).  This patients records do not document standard testing with ferning/nitrazine prior to the AmniSure testing. All told, there is insufficient evidence supporting the superior efficacy of the AmniSure test over standard testing with ferning/nitrazine.  Therefore, the AmniSure test performed on 4/7/14 was not likely to be more beneficial than the available standard for evaluating the patients medical condition. Based upon the information set forth above, the test 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.