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

Summary Reviewer 

The parent of a three-year-old male enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient mental health treatment for children and adolescents provided from 12/31/18 through 6/29/19. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. With regards to risk of harm, the records support a score of 2 due to the patients history of impulsive behaviors. In terms of functional status, the records support a score of 2. The patient has had deterioration in expected level of functioning in relationships with peers, adults and family, and he is struggling with serious daily behavioral issues. In terms of comorbidity, the records support a score of 1. The patient does not have medical problems or substance use. With regards to level of stress of the recovery environment, the records support a score of 3. The patient has problematic issues with family relationships. In terms of level of support of the recovery environment, the records support a score of 2. The patients family actively participates in treatment, although their relationship appears to be strained. With regards to resiliency and treatment history, the records support a score of 3 due to recent minimal progress in the intensive outpatient program. In terms of acceptance and engagement of the child, the records support a score of 3. The patient participates minimally. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians. Thus, the patient has a composite score of 18. The score correlates with intensive outpatient program services. Therefore, intensive outpatient mental health treatment for children and adolescents provided from 12/31/18 through 6/29/19 was and is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 64-year-old male enrollee has requested reimbursement for the DecisionDx melanoma assay testing provided on 9/1/16. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the records indicate the patient presented to his provider with a recently diagnosed 1.4 mm Breslow depth melanoma on the left flank. The National Comprehensive Cancer Network (NCCN) has determined that this type of gene testing for melanoma is not recommended for routine use and should not be used outside of a clinical trial setting. Currently, the DecisionDx melanoma gene test is not considered to be the standard of care. The DecisionDx melanoma gene test is based on studies of ocular melanoma and it has not established that the findings are extended to cutaneous melanoma. For these reasons, the DecisionDx melanoma assay testing provided on 9/1/16 was not medically necessary for evaluation of this patients melanoma. Based on the foregoing discussion, the testing at issue was 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

The patient is a 63-year-old male with a history of urothelial cancer status post resection. The patient developed gross hematuria and computed tomography (CT) abdomen in August 2015 revealed left hydroureter and mild left hydronephrosis with soft tissue attenuation seen in distal left ureter. The patient underwent FoundationOne testing on 5/4/16. The patient is requesting reimbursement for the FoundationOne gene testing performed on 5/4/16. The Health Insurer has denied this request as investigational. The FoundationOne gene testing performed on 5/4/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The National Comprehensive Cancer Network (NCCN) guidelines do not include next generation sequencing in the treatment of urothelial cancer. Clinical outcomes in the treatment of metastatic bladder cancer is not based on complete genomic panel testing. Broad genomic panel testing such as FoundationOne is not considered the standard of care in tis clinical setting. The available literature on clinical utility consists of a small number of uncontrolled studies, and nonrandomized controlled trials that use imperfect comparators. This evidence is not sufficient to make any conclusions on clinical utility. In addition, there is potential for harm if ineffective therapy is given based on test results, because there may be adverse effects of therapy in absence of a benefit. All told, the testing at issue 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 54-year-old female enrollee requested authorization and coverage for arthrodesis sacroiliac joint percutaneous. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees bilateral sacroiliitis. The physician reviewer found There is a growing body of literature looking at sacroiliac fusion and minimally invasive SI fusion in particular. This included randomized controlled trials, a few systematic reviews, and multiple other peer-reviewed studies. However, there continues to be concerns about the quality of the literature available and inherent biases present with many of the studies being industry sponsored and a lack of high level evidence and homogeneity of patient populations and outcome measurements.  Furthermore, there are still concerns with symptom overlap from SI joint and other closely related pathology.  Based on the patients generalized pain profile as outlined in her subjective pain complaints and pain diagram, as well as the underlying diagnoses of chronic lower back pain and fibromyalgia, there is no clear evidence supporting that the requested services will likely be more beneficial than the available standard therapy for treatment of this patients medical condition. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 62-year-old female has requested reimbursement gene testing performed on 11/01/15. 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 has not demonstrated the superior efficacy of the services at issue in this clinical setting.  There is a lack of data supporting an enhanced survival benefit for the use of molecular profiling in the front-line setting for treatment, as few actionable mutations are identified and primary treatment strategies are relatively standard.  The role in recurrent/refractory disease is developing and identification of specific targets for either clinical trial selection or selection of chemotherapy agents may be helpful, although this has yet to be proven.  Thus, gene testing performed on 11/01/15 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: Overturned

Summary Reviewer 3 
A 52-year-old male insured has requested authorization and coverage for Panzyga (immune globulin 
(Human)-ifas). The Health Insurer has denied this request indicating that the requested treatment is 
considered investigational for the treatment of the insureds small fiber neuropathy and paresthesia of 
the feet. The physician reviewer found that the records indicate that this patient has a history of small 
fiber neuropathy and CISP. A study by Koh and colleagues reported that early, aggressive  immunotherapy with IVIG is an effective treatment option for patients with CISP. Similarly, Shelly and 
colleagues found that immunotherapy benefitted 93% of patients with CISP. In this case, the patient has 
previously undergone treatment with IVIG with an improvement of symptoms and function. The 
discontinuation of IVIG led to a resumption of the patients symptoms. Moreover, the patient has tried 
and failed numerous medications, including Effexor, Elavil, Lyrica, Cymbalta, gabapentin, meloxicam, 
mexiletine, and topical lidocaine. Overall, the medical literature and the patients past treatment 
success with IVIG indicate that IVIG therapy is likely to be efficacious for this patient. All told, the 
requested Panzyga (immune globulin (Human)-ifas) is likely to be more beneficial for the treatment of 
the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 35-year-old male enrollee has requested reimbursement for rhinoplasty, secondary; major revision (nasal tip work and osteotomies) performed on 11/13/15. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees nasal obstruction. The physician reviewer found that functional rhinoplasty has been demonstrated to improve nasal breathing by addressing structural abnormalities of the nose. However, there was no documentation of preoperative physical examination describing these abnormalities except for the operative note describing valve collapse on the right. Internal valve collapse can lead to nasal obstruction. Placement of precise cartilage grafts have been demonstrated to provide support which improves nasal breathing. This patient had valve collapse, and vestibular stenosis repair should improve his nasal breathing. Therefore, this procedure was medically indicated. However, the osteotomies, cephalic trim and alar reduction were likely cosmetic and not medically necessary. As such, the rhinoplasty was not medically necessary because the osteotomies and tip work were cosmetic in nature. Therefore, the rhinoplasty, secondary; major revision (nasal tip work and osteotomies) performed on 11/13/15 were not medically necessary. 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 2 
A 30-year-old female enrollee has requested reimbursement for genetic testing on 4/14/22. The 
Health Insurer has denied this request and reported that the service at issue was investigational for 
the evaluation of cystic fibrosis of the enrollees fetus. The physician reviewer found that Hurt and 
colleagues report that isolated echogenic bowel was associated with an increased risk of congenital 
anomalies. Echogenic bowel is diagnosed in 0.2% to 1.4% of second trimester ultrasonographic 
examinations and occurs as a normal variant in the second trimester but has also been associated 
with several pathologic conditions that include cystic fibrosis, chromosomal abnormalities, and in 
utero infection with cytomegalovirus and toxoplasmosis. The diagnosis of fetal echogenic bowel 
in the second trimester has significant implications for prenatal management. The SMFM notes, 
For fetuses with isolated echogenic bowel, we recommend an evaluation for cystic fibrosis and 
fetal cytomegalovirus infection and a third-trimester ultrasound examination for reassessment and 
evaluation of growth. The risk for cystic fibrosis ranges from zero to 13% in the presence of 
isolated echogenic bowel. The finding of dilated loops of bowel in addition to echogenic bowel 
may increase this risk to as high as 17%. Parental cystic fibrosis carrier status should be determined 
if not previously assessed in the current or a previous pregnancy. If both parents are carriers, 
genetic counseling should be undertaken to discuss the risks and benefits of invasive testing for 
fetal genotyping. Racial and ethnic limitations of current cystic fibrosis screening panels should 
be considered when interpreting test results. While the American College of Medical Genetics 
(ACMG) recommends testing for the 23 most common mutations, current medical literature notes 
that there is a lack of coverage for diverse populations by the 23 variants recommended by the 
ACMG. Beauchamp and colleagues report, Modern next generation sequencing (NGS) and 
variant  interpretation  enable  accurate  sequencing-based  cystic  fibrosis  screening.  Limiting  screening to 23 variants does not improve analytical validity, clinical validity, or clinical utility, 
but does fail to detect approximately 30% of at-risk couples. In this clinical setting, the service at 
issue  was  likely  to  have  been  more  beneficial  than  the  standard  screening  of  23  variants 
recommended by the ACMG, which may result in missed cases of cystic fibrosis. Therefore, 
genetic testing on 4/14/22 was likely to have been more beneficial for evaluation of the patients 
condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 26-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/15/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that various (mostly retrospective) studies of prognostic gene expression profiling (GEP) testing suggest its role as an independent predictor of worse outcome, although not superior to Breslow thickness or sentinel lymph node status. It remains unclear whether this GEP profile is reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation studies are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Existing and emerging GEP platforms and other prognostic techniques should also be compared with optimized contemporary multivariable phenotypic models. Therefore, DecisionDx-Melanoma testing performed on 4/15/19 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 50-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/03/18. 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 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 a 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. Thus, DecisionDx-Melanoma testing performed on 8/03/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

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 patients with vaginitis can be evaluated and treated with an examination, microscopy and/or cultures, depending on the patients symptoms and findings. This patient reported itching and discharge. The services performed in this patients case were clinically appropriate. Per the American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin number 215, Although microscopy with Amsel criteria and Gram staining with Nugent scoring remain the preferred methods and the most cost-effective way to diagnosis bacterial vaginosis, some newer commercially available diagnostic tests show promise for use in the clinical setting and may be considered when microscopy is unavailable. Per the medical evidence, this single-swab multiplex test may be a promising alternative to microscopy. Thus, PCR testing performed on 3/18/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 21-year-old female enrollee has requested authorization and coverage for placement of a cardiovascular defibrillator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollee who has a family history of early repolarization syndrome (ERS) and an episode of syncope. The physician reviewer found The patient is a 21-year-old female with a family history of early repolarization syndrome (ERS) confirmed by genetic testing demonstrating mutations in the gene encoding for the ATP-sensitive potassium (+) channel. Her parents are heterozygous for genetic variants associated with the condition. The patient has a brother who had an aborted sudden cardiac arrest during exercise and who is homozygous for both variants. The patient has another brother who had syncope and who is heterozygous for both variants.  The brothers have defibrillators in place.  The patient was determined to be homozygous for the same two variants.  In addition the patient has had two episodes of documented unexplained syncope. The treating provider recommended placement of cardiovascular defibrillator. The Health Insurer denied coverage for the implantable defibrillator as investigational for treatment of this patient. The medical literature supports the requested device for patients who have a genetic predisposition to sudden cardiac death, as evidenced by clinical events in first degree relatives and confirmation of shared genetic variants associated with the condition. (Priori, et al). ERS is associated with an increased risk of idiopathic ventricular fibrillation and sudden death (Adler, et al).  Based on the records provided, the patient has a strong family history of ERS with clinic events as well identified shared gene defects associated with the condition. The patient also reported a personal history of unexplained syncope.  In this circumstance of a strong family history of aborted sudden cardiac arrest in first degree family members, symptoms of syncope, and confirmation of shared homozygous genetic variants associated with the condition, placement of a defibrillator is highly effective and considered standard accepted practice in the medical community.  Moreover, the patients personal history of syncope strengthens the likely benefit for defibrillator placement. As such, the placement of cardiovascular defibrillator is likely to be superior to other forms of therapy available for the treatment of this patient. Therefore, for the reasons stated above, the cardiovascular defibrillator 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 3

A 57-year-old male enrollee has requested gene testing performed on 9/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees uveal melanoma.  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The only clinical information available for review are the requisition and report of test results. Per the medical evidence, management includes surveillance testing. However, there was insufficient information submitted to determine if there were other features of the patients clinical situation that would make him moderate or high risk.  Therefore, there is insufficient information to determine whether the services at issue were likely to be more beneficial than any available standard therapy.  Thus, gene testing performed on 9/11/17 was not 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 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 60-year-old male enrollee has requested reimbursement for Oncotype testing performed on 4/25/19. 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 National Comprehensive Cancer Network guidelines indicate that men with low or favorable intermediate risk disease post biopsy may consider the use of tumor-based molecular assays, such as Oncotype DX testing. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays.  It is considered a standard of care in guiding treatment decision making. In sum, Oncotype DX testing performed on 4/25/19 was likely to have been more beneficial than other methods of evaluating this patient.