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

Summary Reviewer 2

A 53-year-old male enrollee has requested authorization and coverage for Inspire upper airway stimulation system.  The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees medical condition. The physician reviewer found in this patients case, the requested Inspire upper airway stimulation system is likely to be more efficacious than other treatment option.  The records document that the patient has tried multiple prior therapies to assist in the management of severe sleep disorder.  He has a long history of objective evidence of sleep apnea and meets criteria for management.  Normal management of obstructive sleep apnea is with the use of CPAP therapy.  However, this patient became intolerant of the use of this device.  This patient meets the criteria established for the implantation of the requested device.  Medical reports are now demonstrating the long-term effectiveness of this method of 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for mental health residential treatment center services provided from 2/27/15 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 behavioral health condition. The physician reviewer found this patient has significant impulse control problems, related to his diagnoses of autism, ADHD and cerebral dysrhythmia. He has little insight into the nature of his problems and only seems reluctantly to admit that he could cause significant harm to others and even himself. The progress notes indicate that he still struggles with violent thoughts of raping women he encounters in his environment. The documentation submitted for review indicates that his symptoms are quite severe. In addition, there are few facilities that have the experience and expertise to treat such an individual.  It is unlikely that an outpatient or partial hospital program could meet his needs and also ensure the safety of others in the community. In sum, treatment in a 24-hour facility is clinically indicated for this patient.  Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 51-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma Assay (CPT code 84999 - unlisted chemistry procedure) provided on 1/17/17. 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 melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. DecisionDx-Melanoma Assay assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class 1 consistent with a low risk of metastasis or Class 2 suggestive of a high risk of metastasis. One peer-reviewed publication indicated that there was a statistically significant association of a Class 1 signature by DecisionDx-Melanoma Assay for primary dermal melanoma (PDM), whereas cutaneous metastatic melanoma (CMM) were more frequently Class 2 (Sidiropoulos, et al). The authors concluded that the melanoma prognostic assay may be a useful tool for distinguishing PDM from CMM. Therefore, DecisionDx-Melanoma Assay signature may be an independent predictor of metastasis risk. However, there is a lack of peer-reviewed published studies confirming this hypothesis. All told, the DecisionDx-Melanoma Assay performed on 1/17/17 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 1

The parent of a 12-year-old male enrollee has requested authorization and coverage for Remicade 400 mg for two weeks and then once monthly for one year. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees juvenile dermatomyositis (JDMS). The physician reviewer found remicade is likely to be more effective for this patient than other available treatment options. This patient has JDMS and has been treated with numerous treatments, which have been either ineffective or partially effective. The patient was doing better while on IVIG, but developed headaches after the infusions, which is a common side effect. After stopping IVIG, the patient has become weaker with his creatine kinase (CK) levels increasing. The medical literature supports infliximab for the treatment of refractory myositis demonstrating beneficial effect with improved motor strength, decrease in fatigue, and a decrease in CK. Thus, infliximab is clinically indicated for this patient with JDMS and 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 services are 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: Overturned

Summary Reviewer 


A 21-year-old male enrollee has requested authorization and coverage of Humira pen psoriasis-uveitis 40 mg/0.8 mL pen injector kit. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees plaque psoriasis.
 The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. The records indicate that this patient is a poor candidate for systemic treatments. He not a candidate for treatment with methotrexate as he drinks alcohol and may be trying to conceive a child. He should also avoid a systemic retinoid like Soriatane as he has elevated triglycerides and Soriatane has the side effect of raising triglyceride levels. Cyclosporine is not recommended since this patients medical condition is a chronic disease and there are long term risks with use of cyclosporine. On the other hand, Humira has been shown effective as a treatment option and it has strong safety ratings. Additionally per available data, Humira has better efficacy than methotrexate or cyclosporine in this clinical setting. According to the American Academy of Dermatology and the medical literature, Humira is a standard treatment option for treatment of chronic plaque psoriasis. Humira is also U.S. Food and Drug Administration approved. As such, Humira pen psoriasis-uveitis 40 mg/0.8 mL pen injector kit is medically necessary for the treatment of this patients medical condition. Therefore, based on the information noted above, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 55-year-old male enrollee has requested authorization and coverage for an electrical stimulation device.  The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees medical condition. The physician reviewer found the current medical evidence supports the superior effectiveness of the requested device in this clinical setting.  Optune is a type of alternating electric field therapy which is U.S. Food and Drug Administration (FDA) approved for recurrent/progressive disease in patients with glioblastoma multiforme.  It is considered a standard of care based on a follow-up study showing prolonged progression free and overall survival.  Consensus-based guidelines published by the National Comprehensive Cancer Network include alternating electric field therapy as a treatment option for patients with recurrent glioblastoma.  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: Overturned

Summary Reviewer 1


A 46-year-old female enrollee has requested authorization and coverage for total disc arthroplasty (CPT 22858 and 22856).  The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition. The physician reviewer found there is sufficient support for the requested services in this clinical setting.  The evidence-based literature supports the use of two-level contiguous cervical artificial disc replacement as an option over anterior cervical discectomy and fusion for the treatment of symptomatic degenerative disc disease.  This patient presents with neck pain radiating into the right arm with weakness.  Clinical examination findings are consistent with imaging evidence of neural compression and spondylosis at the C5-6 and C6-7 levels. Per the medical records, a conservative nonoperative treatment has been tried and failed to provide sustained improvement. The use of two-level artificial disc replacement will allow for motion preservation, which would be sacrificed with the use of fusion.  Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 59-year-old female enrollee has requested reimbursement for HCMNext Reflex-Ambry genetic test performed on 10/2/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollee, who has a history of hypertrophic cardiomyopathy. The physician reviewer found that the documentation provided does not support the testing at issue was likely to have been more effective when compared to available standard methods of evaluating this patient. The patient did not complain of lightheadedness or palpitations and had no other non-invasive evaluation prior to genetic testing. There was no evidence provided that the genetic testing offered prognostic information. While the patient has evidence of hypertrophic cardiomyopathy by echocardiography, the provider calculated a 2.09% five year risk of sudden cardiac death and opined that she was not a candidate for prophylactic implantable cardioverter defibrillator placement. In spite of the positive results from the genetic testing for a pathogenic variant associated with a diagnosis of hypertrophic cardiomyopathy, the records provided for review do not support any change of the patients therapy based on these results. The patient was recommended for a one year follow up with the cardiologist provider which would indicate clinical stability.  Accordingly, HCMNext Reflex-Ambry genetic testing performed on 10/2/17 was not likely to have been more beneficial than the standard evaluation techniques available for treating this patient.

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 2

A 60-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/10/19. 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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individualas melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear if the assay can be used to make clinical decisions. All told, DecisionDx-Melanoma testing performed on 10/10/19 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 62-year-old female enrollee has requested authorization and coverage for Harvoni.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, non-cirrhotic genotype 1 patients who have failed peg-interferon and ribavirin should be treated with Harvoni for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  For these reasons, Harvoni is medically indicated for the treatment of this patient.  Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 55-year-old female enrollee has requested reimbursement for inpatient services provided on 4/03/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees palpitations. The physician reviewer found that the patient presented with complaints of tinnitus without any other neurologic complaints. She was hemodynamically stable, without any neurologic deficits on examination. The inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. Thus, inpatient services provided on 4/03/17 were not medically necessary 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: Upheld

Summary Reviewer 3

A 70-year-old male enrollee has requested authorization and coverage for DecisionDx-Melanoma testing performed on 10/28/16. 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 the data on the DecisionDx test for melanoma is not 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 was also the consensus opinion of the National Comprehensive Cancer Network (NCCN) guidelines. 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 they suggest a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon alpha. In sum, DecisionDx-Melanoma testing performed on 10/28/16 was not likely to have been more effective than the available options for the evaluation of this patients medical condition. 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 45-year-old male enrollee has requested has requested reimbursement for the testosterone pellet (Testopel) 75 mg received on 12/18/15. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees hypogonadism. The physician reviewer found that low testosterone can lead to such complications as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue (Dandona and Rosenberg). For these reasons, many providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dL (Nieschlag, et al). The general target level for testosterone ranges from 350 to 750 ng/dL, which is approximately the range for healthy, androgen-sufficient adult men. Testosterone levels should be monitored for three to six months after initiation of treatment in order to assure that the patients testosterone level is optimal and the dose of testosterone replacement therapy should be adjusted accordingly (Rivas, et al). Testopel, which measures 3 mm by 9 mm, is an implantable testosterone pellet containing crystalline testosterone which are implanted under the skin and slowly release testosterone over the course of three to six months. Benefits include relatively long duration of action and reduced risk of exposure to other individuals via skin contact (Margo and Winn). In this case, the patient was unable to remain on topical testosterone therapy, and he has derived benefit from treatment with Testopel 75 mg. Therefore, the Testopel 75 mg received on 12/18/15 has been established as medically necessary for treatment of the patients medical condition.  Therefore, the medication at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 49-year-old male enrollee has requested reimbursement for a positron emission tomography (PET) scan performed on 6/30/17. 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 very limited clinical information has been submitted concerning this patient. For some reason, a CT scan was obtained which demonstrated what was described as bulky adenopathy in the retroperitoneum, mesentery, and supraclavicular regions.  Lymphadenopathy is a common clinical presentation, and the first role of the provider is to determine whether this represents a significant systemic disease or whether the lymphadenopathy is likely due to a local inflammatory (and likely self-limited) reaction.  But when one has evidence of multisite bulky adenopathy, it can be assumed that this represents a significant illness. The next step is to differentiate between benign and malignant processes. In this patients case, considering the likely diagnosis of lymphoma, his providers proceeded with a bone marrow aspiration which was negative.  One critical issue is to decide on a node to biopsy that is both accessible as well as likely demonstrating an answer. It is in this situation where PET scanning is the most optimal next step.  By demonstrating metabolic activity, the provider can safely pick the most suspicious node to sample. In this case, obtaining a PET/CT scan was warranted, and is the typical common means to proceed in patients with this presentation. In sum, PET scan performed on 6/30/17 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: Upheld

Summary Reviewer 

A 45-year-old male enrollee has requested authorization and coverage for Xyrem. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient was diagnosed with narcolepsy in 2015 by a multiple sleep latency test (MSLT), which was preceded by an overnight polysomnography sleep study. After reviewing the result of the sleep study and MSLT, these studies were inconclusive and technically inadequate. The patient slept only 228 minutes, while at least 360 minutes is required per American Academy of Sleep Medicine guidelines to have adequate MSLT test results. In addition, the MSLT showed an average sleep latency of 9 minutes and 48 seconds, while the guidelines for positive MSLT is less than 8 minutes. The results from his sleep studies cannot be considered adequate to support the diagnosis of narcolepsy. Xyrem is indicated to treat appropriately diagnosed narcolepsy patients with or without cataplexy if there is contraindication or poor response to other medications. There is a lack of support for the requested medication in this clinical setting. Therefore, Xyrem is not medically necessary for the treatment of this patient.