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

Summary Reviewer 1

A 58-year-old female enrollee has requested reimbursement for MammaPrint testing performed on 1/21/14. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for the evaluation of the enrollees breast cancer. The physician reviewer found the testing provided on 1/21/14 was not likely to be more effective for this patient than other available treatment options. The National Comprehensive Cancer Network (NCCN) guidelines state MammaPrint is approved by the [U.S. Food and Drug Administration] FDA to assist in assignment of women with ER-positive or ER-negative breast cancer into a high versus low risk for recurrence, but not for predicting benefit from adjuvant system therapy. NCCN guidelines further state that studies using MammaPrint as a prognostic or predictive tool are too small and/or retrospective in nature. In sum, 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: Upheld

Summary Reviewer 3


The parent of a 17-year-old male enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 6/30/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the Anser IFX test was ordered to determine the drug concentration for Remicade at the end of induction.  This is not standard in the management of ulcerative colitis.  The use of Prometheus Anser IFX 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 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.  Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing.  Per the current medical evidence, Prometheus Anser IFX testing performed on 6/30/14 was not likely to have been of greater benefit than other modalities.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 44-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 3/18/16.  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 that there is sufficient support for digital breast tomosynthesis for the evaluation of patients for breast cancer screening. Digital breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often enables the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks, increase in accuracy and increase in detection of small cancers. For this reason, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely of greater benefit to the patient than had the examination been performed using two dimensional imaging alone.  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: Overturned

Summary Reviewer 2

The patient is a 62-year-old male with a T1c Gleason 3+3 prostate cancer. His tumor was sent for OncotypeDX Prostate Cancer on 2/14/17 to help guide treatment decision making. The Health Insurer has denied this request indicating that the services at issue were considered investigational for the evaluation of the patients prostate cancer. The patient has requested reimbursement for the gene expression profiling OncotypeDX prostate cancer assay performed on 2/14/17. The Health Insurer has denied this request on the basis that the services at issue were investigational for the evaluation of this patients medical condition. The National Comprehensive Cancer Network (NCCN) recommends testing with OncotypeDX post biopsy for NCCN very low and low risk prostate cancer in patients with at least 10 years life expectancy who have not received treatment for prostate cancer and are candidates for active surveillance or definitive therapy. Men with clinically localized disease may consider the use of tumor based molecular assays. Retrospective case cohort studies have shown that molecular assays performed on biopsy or prostatectomy specimens provide prognostic information independent of NCCN risk groups. These include, but are not limited to, likelihood of death with conservative management, likelihood of biochemical progression after radical prostatectomy or external beam therapy, and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. The OncotypeDX assay is considered standard of care in guiding treatment decision making for patients with low risk prostate cancer. Accordingly, the gene expression profiling OncotypeDX prostate cancer assay performed on 2/14/17 was likely to have been more beneficial than any available standard therapy for the evaluation of this patients medical condition.  Therefore, for the reasons stated above, the services at issue were likely to have been 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: Overturned

Summary Reviewer 3

The parent of a 16-year-old male enrollee has requested reimbursement for the comparative genomic hybridization (CGH) testing performed on 4/26/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for the enrollees dysmorphic facies and postural and kinetic tremor. The physician reviewer found thatCGH, also known as chromosomal microarray (CMA), is recommended by the American College of Medical Genetics (ACMG) as a first-tier test for patients with autism spectrum disorders or developmental delay and intellectual disability. The yield of CMA in patients with these disorders is estimated to be around 10%. However, there is no indication that this patient has these conditions. The clinic notes report that he has anxiety and depression with hallucinations, tremor, and differences in sensation. The notes also mention mild dysmorphic features, however these were not specified. In this clinical setting, the yield of CMA is likely to be low for this patient. As such, the CGH testing performed on 4/26/16, 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 63-year-old male enrollee has requested authorization and coverage for implantation of cranial nerve stimulator. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who has been diagnosed with acute obstructive sleep apnea. The physician reviewer found that the patient is a 63-year-old male who has a history of obstructive sleep apnea (OSA) and poor sleep. He is status post palate surgery and septoplasty. He underwent sleep endoscopy which revealed antero-posterior collapse at the velum and base of tongue. His Epworth sleepiness scale was reported at 4/24. He had a body mass index (BMI) of 34.6 when he underwent a polysomnography in 2013. That study also revealed an apnea-hypopnea index (AHI) score of 56.5. On 11/24/15, another sleep study was performed. The patients AHI score was document at 34.5. He failed continuous positive airway pressure (CPAP) therapy and was treated with bilevel therapy. The treating provider discussed implantation with cranial nerve stimulator as an option for treatment. The patient requests authorization and coverage for implantation of cranial nerve stimulator. The Health Insurer denied this request as investigational for treatment of this patients medical condition. OSA is an increasingly prevalent clinical problem with significant effects on both personal and public health. CPAP has demonstrated excellent efficacy and low morbidity with long-term adherence rates approaching 50%. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. The STAR trial demonstrated that cranial nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA (Woodson, et al). However, these studies were performed in a subset of patients with OSA. Patients with concentric airway collapse, BMI greater than 32 and AHI less than 20 or greater than 50 were excluded. In this patients case, his BMI was 34.6 and his recent AHI was 34.5. All told, in this patients case, the current medical evidence does not support the superiority of implantation of cranial nerve stimulator over the available standard treatment options. 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: Overturned

Summary Reviewer 3

A 60-year-old female enrollee has requested authorization and coverage for a heart monitor (implantable ambulatory event monitor). The Health Plan has denied this request indicating that the requested device is considered investigational for treatment of the enrollees syncopal episodes. The physician reviewer found the request for a heart monitor (implantable ambulatory event monitor) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The ILR is a non-invasive diagnostic device that is often of great clinical use in this clinical setting, since it can remain in place for long periods of time and provide information about arrhythmias when other techniques have not been revealing. In this case, the patient has syncope with head trauma and previous evaluation has not determined the cause of syncope. The patients symptoms are described as infrequent and the extensive work-up was performed years. The requested device is likely to provide better information than a 30-day monitor or any other type of monitor currently available. Moreover, the use of the ILR is in accordance with American College of Cardiology guidelines. For the reasons provided, the requested device 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 device 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: Upheld

Summary Reviewer 1


A 40-year-old male enrollee has requested reimbursement for acupuncture services (CPT code 97810) provided from 8/13/15 through 10/31/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees abdominal pain. The physician reviewer found the acupuncture services (CPT code 97810) provided from 8/13/15 through 10/31/15 were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of peer-reviewed medical literature supporting acupuncture as more beneficial than standard therapy. Li and colleagues reviewed the efficacy of acupuncture as a treatment for gastrointestinal (GI) dysfunction and the associated underlying mechanisms. The authors concluded that further studies are needed to investigate the effects and more systematic mechanisms in treating GI dysfunction, and to promote the application of acupuncture for the treatment of GI diseases. In addition, the documentation provided for review does not show the patients pre- and post-care condition to compare the functional gains and medication intake reduction obtained with the acupuncture performed. Accordingly, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, 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: Upheld

Summary Reviewer 1

A 70-year-old male enrollee has requested reimbursement for service code 97139, unlisted therapeutic procedure, performed on 4/20/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the specifics of how the service in question is physically administered upon patients are not described in the medical literature. There is no clear description of the technique on the serviceas website. The website makes no reference to any published, peer-reviewed, medical, scientific or clinical studies involving this service specifically. The technical features of this service appear proprietary. As best as can be discerned from the records provided by the facility where the patient received this service, the service involves a patient being secured to a thoracic harness and a pelvic harness, with tension then applied. The patient in this case received 50 lbs of tension for 25 minutes on his earlier visits, and this was gradually increased to 100 lbs of tension for 25 minutes by mid/late June 2020. The service in question, overall, appears to be a lumbar traction table, likely provided in an intermittent/cyclical manner, and marketed in a manner to suggest that exposure to this device improves an intervertebral discas health or anutrition.a
There is no reasonable expectation that exposure to the service in question will provide any health or functional benefits that would be different to exposure to other types of lumbar traction devices. This is to say that no health or functional benefits would be expected from exposure to this specific device. The intervertebral discs are routinely offloaded from pressure in the recumbent position (e.g., during sleep). There is no proven clinical benefit of providing exogenously applied force aimed at distraction of the discs, whether continuously or rhythmically. The literature, overall, does not support the use of lumbar traction for back pain conditions attributed to disc degeneration or pathology. The support for the use of this type of intervention is anecdotal. The focus of treatment of benign, musculoskeletal/mechanical low back pain includes patient education (particularly with respect to the natural history of the condition), independently applied topical modalities for palliation, common analgesics for palliation, if warranted, exercise and remaining active. The service in question was not likely to have been more beneficial for treatment of the patientas condition than routine management involving the above. There are no simple, proven interventions (including lumbar traction) that provide marginally superior benefits than the above. Therefore, the unlisted therapeutic procedure provided on 4/20/20 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 56-year-old female with osteoporosis. Her provider has prescribed Prolia for the treatment of this condition. The patient has requested authorization and coverage for Prolia 60 mg injected every six months for one year.  The physician reviewer found that the patient has been diagnosed with osteoporosis. Four agents (alendronate, risedronate, zoledronic acid and denosumab) have evidence for broad spectrum anti-fracture efficacy and should generally be considered as initial options for most patients who are candidates for treatment. There is a lack of head-to-head trials with a preplanned endpoints of fractures comparing one drug with another. Bisphosphonates (alendronate, risedronate and zoledronic acid) are usually the first-line of therapy. Prolia (denosumab) has been approved by the U.S. Food and Drug Administration for the treatment of osteoporosis in postmenopausal women at high-risk of fracture. Denosumab reduces the incidence of vertebral fractures by about 68%, hip fractures by about 40% and nonvertebral fractures by about 20% over three years. Per the medical evidence, Prolia is likely to be effective in treating the patients osteoporosis and in decreasing the risk of bone fracture. Therefore, Prolia 60 mg injected every six months for one year is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 29-year-old female enrollee has requested authorization and coverage for compound medication of sirolimus cream 1%. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollee, who has Klippel Trenaunay syndrome. The physician reviewer found that the treatment of rare vascular malformations is multidisciplinary, as this patient has been receiving. She has already been treated with laser and surgery and is still developing new blebs, placing her at risk for bleeding and infection. There is a lack of standard therapies for this disease. The use of topical sirolimus is likely to be more beneficial for the patient than the previous treatments she has tried. Promising results have been reported in preliminary studies. Therefore, compound medication of sirolimus cream 1% is likely to be of greater benefit than other available treatment options. 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 35-year-old female enrollee has requested reimbursement for BRCA1, BRCA2 (breast cancer 1 and 2) (hereditary breast and ovarian cancer) gene analysis, full sequence analysis and common duplication/deletion variants in BRCA1 performed on 12/07/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the submitted documentation does not support the medical necessity of the services at issue. While the lifetime risk score completed by Myriad MyRisk was estimated to be 29.6%, higher than the 20% lifetime risk considered threshold for changes in management, this indicates that the patient should be considered for earlier or increased breast screening, not necessarily that genetic testing of BRCA1 and BRCA2 were indicated. Genetic testing for hereditary cancer predisposition syndromes are most useful in individuals who have a personal history of cancer or in those who have affected family members with known mutations. In this patients case, negative BRCA1 and BRCA2 testing did not reduce her risk, as the records do not document the cause of cancer in any of her family members, particularly in the paternal aunt, who is the only relative with cancer at a young age. The current medical evidence does not support the services at issue in this clinical setting. Therefore, BRCA1, BRCA2 (breast cancer 1 and 2) (hereditary breast and ovarian cancer) gene analysis, full sequence analysis and common duplication/deletion variants in BRCA1 performed on 12/07/18 were not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 63-year-old female enrollee has requested reimbursement and prospective authorization and coverage for physical therapy provided from 8/17/15 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found according to the documentation submitted for review, the patient had post-operative disability after foot surgery and physical therapy was prescribed to improve function. The patient made improvement in physical therapy through 8/19/15. On that date further physical therapy was reasonable and medically necessary because the patient had continued deficits that are generally amenable to the care of a skilled physical therapist. Based on improvement up to 8/19/15, further improvement could be expected with skilled services. However, the patient did not show further improvement. As such, six additional physical therapy sessions after 8/19/15 were sufficient to show a plateau. After these six sessions, the patient could have been managed with a home exercise program. For the reasons provided, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1
A 54-year-old female has requested reimbursement for chemotherapy treatment provided from 10/06/17 through 12/13/17. The Health Insurer has denied this request indicating that the medication regimen at issue was considered investigational for treatment of the enrollees gallbladder cancer. The physician reviewer found that FOLFIRI regimen (without bevacizumab) has an acceptable toxicity profile and a good activity, mainly in the second-line treatment. Improved overall survival and progression-free survival were found in patients who achieved partial response or stable disease. Hence, this regimen is considered standard. However, there is a lack of support for FOLFIRI with Avastin. This combination has not been tested in a randomized clinical trial showing a survival benefit. A number of phase II studies have been published showing safety only. Efficacy as measured by overall survival and progression-free survival has not been demonstrated with this combination. Therefore, the superior efficacy of the chemotherapy treatment provided from 10/06/17 through 12/13/17 has not been established. Based upon the information set forth above, the medication regimen at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.