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

Summary Reviewer 3

The patient is a 64-year-old female who presented to the neurosurgery clinic after being diagnosed with a right carotid occlusion and high-grade stenosis of the left carotid artery.  She has a history of several transient ischemic attacks with complaints of dizziness as well as headaches and blurry vision. The patient underwent left internal carotid artery angioplasty and stenting on 2/27/18.  The angiogram noted high-grade stenosis of the right vertebral artery is 70%, and a computed tomography (CT) perfusion revealed decreased blood flow to the right occipital lobe. During the postoperative examination, she continued with symptomatic dizziness, and the recommendation was made for right vertebral artery angioplasty with stenting.  The provider noted she is at increased risk for stroke should she become dehydrated or hypotensive given the carotid occlusion and stenosis of the right vertebral artery. The patient has requested coverage for vertebral artery angioplasty. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient.  This patient has been recommended to undergo a vertebral artery angioplasty due to vertebral artery occlusion.  The patient underwent left internal carotid artery angioplasty and stenting on 2/27/18 and was noted to have a follow-up on 3/06/18 where she indicated she was doing well. She did complain of one episode of dizziness. While treatment with the requested surgical intervention may be appropriate in certain situations, it does not appear this patient is an appropriate candidate. There is lack of documentation indicating that the stenosis continues to make the patient symptomatic.  The follow-up note indicated the patient was doing well and only had one episode of dizziness.  Given the above, the requested vertebral artery angioplasty is not likely to be of greater benefit than other 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 reimbursement for collagen crosslinks laboratory tests performed on 1/2/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees osteoporosis. The physician reviewer found that according to the Clinicians Guide to Prevention and Treatment of Osteoporosis, biochemical markers of bone turnover may predict risk of fracture independently of bone density in untreated patients, predict rapidity of bone loss in untreated patients, and help determine adequacy of patient compliance and persistence with osteoporosis therapy. These statements are also supported by Burch and colleagues who performed a review regarding the use of bone turnover markers for monitoring the response to osteoporosis treatment. In this case, identifying baseline and subsequently monitoring markers of bone turnover to assist with best therapy options for the patient is medically appropriate and in line with sound medical practice. The requesting provider indicated that these tests were ordered to monitor compliance and response to anti-resorptive therapy. All told, these tests were likely to be more efficacious to guide the therapy for 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: Experimental
Decision: Upheld

Summary Reviewer 3


A 43-year-old female enrollee has requested authorization and coverage for right sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain.  The physician reviewer found based on the current peer-reviewed medical literature, the requested sacroiliac fusion is not likely to be beneficial for management of chronic pain. Anatomical studies performed after the patient had an L3-4 level fusion and laminectomy suggests likely continuing pain generation from intervertebral disc and facet joints at multiple levels of the lumbosacral spine. The MRI did not show any abnormality in the sacroiliac joint and did not suggest that the sacroiliac joint had been violated by the bone graft. The reliance of steroid local injection into the sacroiliac joint as an indicator for identification of a specific pain generator, i.e. the sacroiliac joint is not sufficient to localize pain generation from the sacroiliac joint in the face of multifactorial chronic pain. In summary, it is not likely to be beneficial for this patient to undergo sacroiliac instrumentation and fusion as a treatment method for her condition of chronic pain. 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 1 
 
A 57-year-old male insured has requested reimbursement for a gene test (CPT 0047U) provided on 
3/10/22. The Health Insurer has denied this request indicating that the services at issue were considered 
investigational for the evaluation of the insureds prostate cancer. The physician reviewer found that the 
records available for review indicate that this patient presented with Gleason 3+3=6 prostate cancer 
with a PSA of 7.74 ng/mL. The current National Comprehensive Cancer Network (NCCN) guidelines 
recommend testing with Oncotype DX post-biopsy for patients with low or favorable intermediate-risk 
prostate cancer. Retrospective studies have shown that molecular assays following prostate biopsy or 
radical prostatectomy can provide prognostic information independent of NCCN risk groups (Chang, et 
al.). One review studied whether the score for a prostate genetic test was associated with prostate 
cancer pathology findings for patients who had their prostate removed (Covas Moschovas, et al.). The 
authors found that their findings may help surgeons in counseling patients on surgical options for 
prostate cancer. Overall, the data suggest that patients with clinically localized disease may be 
considered for the use of tumor-based molecular assays, and this testing is considered the standard of 
care in guiding treatment decision-making. Accordingly, the gene test (CPT 0047U) provided on 3/10/22 
was likely to have been more beneficial for the evaluation of the patients medical condition than any 
available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


An 18-year-old female enrollee has requested reimbursement for the gene testing performed on 9/1/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees major depressive disorder. The physician reviewer found that genetic testing results show if a patient is a normal responder of certain classes of medications, may be more or less likely to respond to certain medications, is at low risk of certain adverse events, at higher risk of others, or may have decreased activity of a certain enzyme activity. However, the fact that there was a gene mutation does not demonstrate that the addition of l-methylfolate will have an effect on this patients treatment. The length of time she was treated with these medications was not given, nor does she appear to have been tried on other classes of antidepressants. All of these issues could have been assessed by the provider during follow-up, and adjusted for by changes in medication regimen including increased/decreased dose, other augmentation strategies, or discontinuation for a variety of reasons. In addition, plasma levels may be higher or lower due to differences in hepatic metabolism that varies in every individual. Furthermore, there is a lack of large randomized trials supporting the use of genetic testing as effective in guiding the clinician towards choosing a medication regimen. Accordingly, the gene testing performed on 9/1/16 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 reimbursement for Decision Dx Assay testing performed on 7/18/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees melanoma.The physician reviewer found the Decision Dx Assay testing performed on 7/18/16 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 indicate that genetic testing such as the Decision Dx Melanoma testing should not be used outside of a clinical trial setting. In this case, the patient presented with melanoma of 0.83 mm Breslow depth located on his back. The use of Decision Dx Assay testing is not the standard of care in the treatment of the patients melanoma. As such, the testing at issue is not expected to impact the treatment or outcome of the patients melanoma. Therefore, 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 2

A 58-year-old male enrollee has requested reimbursement for test for allergy or toxicity (immunoglobulin G (IgG) food sensitivity testing) performed on 3/14/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of diarrhea. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue. The current medical evidence does not support IgG food sensitivity testing in this clinical setting. The American College of Gastroenterology notes that immunoglobulin A (IgA) anti-tissue transglutaminase antibody is the preferred single test for detection of celiac disease in patients over the age of two years. In this patients case, celiac disease had already been endoscopically ruled out. Thus, IgG food sensitivity testing performed on 3/14/18 was not likely to have been of greater benefit 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 2
A 52-year-old female enrollee has requested authorization and coverage for gene test (gene expression profiling) performed on 9/20/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has been diagnosed with cutaneous melanoma. The physician reviewer found that a commercial gene expression profile test (DecisionDX melanoma) has been developed in patients with stage I and II cutaneous melanoma. However, there are no definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials according to published data available. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate benign from malignant neoplasms, or melanomas at low versus high risk for metastasis, routine (baseline) genetic testing of primary cutaneous melanomas (before or following SLNB) is not recommended outside of a clinical study (trial). The gene test (gene expression profiling) performed on 9/20/16 was not likely to have been of greater benefit than available standard therapy for the evaluation of this patients medical condition. 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 33-year-old female enrollee has requested reimbursement for the residential mental health treatment services provided from 3/2/17 through 3/16/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found that the modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general, community intervention settings optimize treatment gains while episodic placement in more restrictive settings can be clinically appropriate for patients with significant mental illness. The American Psychiatric Association (APA) states that the provider should determine the least restrictive setting for treatment that will be most likely not only to address the patients safety, but also to promote improvement in the patients condition. In this particular case, the patient presented with co-occurring bipolarity and anxiety. Patients with bipolar disorder spend a disproportionate time in the depressed phase. This is of particular relevance since it has been well-established in both clinical practice and the medical literature, such as the definitive Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, that anxiety-ridden mood disorders are difficult to treat and in general have poorer outcomes. Further, the patient had previously failed treatment in a less restrictive setting. Thus, the residential admission was indicated. During the disputed timeframe, the patient consolidated treatment gains and remained engaged in active treatment. However, discharge on 3/2/17 would have been premature and more than likely would have resulted in undue morbidity and re-admission. The services and setting were safe, appropriate and consistent with good practice, while the duration of the admission aligned with community standards. Additionally, the services provided were reasonably expected to improve her condition and prevent a more serious episode of illness. Considering the clinical presentation and perusal of the peer-reviewed literature, the residential mental health treatment services provided from 3/2/17 through 3/16/17 were medically necessary for treatment of the patients behavioral health condition. Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 60-year-old male enrollee has requested reimbursement for the subtalar arthrodesis provided on 11/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees hallux valgus. The physician reviewer found that calcaneal osteotomy has been demonstrated to be an effective procedure to control a painful flat foot. However, the concurrent procedure, subtalar arthroereisis, has not been demonstrated in large, randomized controlled clinical trials to provide long-term benefits beyond that anticipated with conservative measures. The data on subtalar arthroereisis in the published medical literature is inadequate to draw scientific conclusions. All told, the subtalar arthrodesis provided on 11/23/15 was 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 55-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the U.S. Food and Drug Administration has approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm. This patient meets those specific criteria. The device is a ring made up of a series of magnets that have sufficient attraction to increase the lower esophageal sphincter closure pressure, but allow for food passage with swallowing. Based upon a prospective study by Lipham and colleagues that included 44 patients, the mean total percent time that pH was less than 4 was reduced from 11.9 percent at baseline to 3.8 percent at three years. A recent study comparing the LINX procedure with laparoscopic fundoplication was performed by Reynolds and colleagues. The authors found that gastroesophageal reflux disease patients had similar control of reflux symptoms after both LINX and fundoplication. The inabilities to belch and vomit were significantly fewer with LINX, along with a significantly lower incidence of severe gas-bloat symptoms. Therefore, the LINX Reflux Management System (code 43284) and one inpatient day are likely to be superior over other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a nine-year-old female. The patient has requested reimbursement for neuropsychological testing performed from 1/18/20 through 8/13/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. Neuropsychological testing indicated that the patient had a complex combination of ADHD combined subtype, non-verbal learning disorders in math and reading, dysgraphia/dyspraxia, and dysthymia with symptoms of anxiety and depression. The patientas symptoms were interfering with her social, academic and family functioning. She was noted to be at risk of social isolation, peer rejection and bullying. The neuropsychological testing and school evaluations that were performed were the only means by which the patientas complex combination of conditions could be clarified, and appropriate intervention instituted. Therefore, neuropsychological testing performed from 1/18/20 through 8/13/20 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 19-year-old male enrollee has requested reimbursement for procedure codes 86671 x 2 and 86021 x 3 performed on 2/14/20. 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 Inflammatory bowel disease (IBD) is a heterogeneous group of chronic inflammatory disorders of the gastrointestinal tract with two main distinguishable entities, Crohnas disease (CD) and ulcerative colitis (UC). IBD-unclassified (IBD-U) is a diagnosis that covers the agreya zone of diagnostic uncertainty between UC and CD. Current diagnosis of IBD relies on the clinical, endoscopic, radiological, histological and biochemical features, but this approach has shortcomings, especially in cases of overlapping symptoms of CD and UC. The need for a diagnostic tool that would improve the conventional methods in IBD diagnosis directed the search towards potential immunological markers, since an aberrant immune response against microbial or endogenous antigens in a genetically susceptible host seems to be implicated in IBD pathogenesis. The spectrum of antibodies to different microbial antigens and autoantibodies associated with IBD is rapidly expanding. However, in this patientas case, where a prior diagnosis of left-sided ulcerative colitis has already been rendered, the provideras reliance on marker testing as the final arbiter as to whether patient instead has CD is not standard of care and is not indicated in lieu of gold standard colonoscopy with biopsies. Therefore, procedure codes 86671 x 2 and 86021 x 3 performed on 2/14/20 were not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

The patient is a 36-year-old male who is under evaluation for gastroesophageal reflux disease (GERD). The patient experiences severe sub-xiphoid pain with exercise or lying down to sleep. The patients symptoms typically occur when eating calorie rich food. The patient has some symptoms consistent with gastroparesis although his gastric emptying scan was normal. He has had an overall poor response to proton pump inhibitor (PPI) therapy. On manometry he has a low lower esophageal sphincter (LES) pressure with small-medium sized hiatal hernia. A pH study was borderline positive with a low DeMeester score. The patient has requested authorization and coverage for transoral incisionless fundoplication (TIF) with EsophyX device. The Health Insurer has denied this request as investigational. The requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. TIF is a minimally invasive treatment for GERD that is performed in the outpatient setting. In the medical literature, Wendling and colleagues reported in a recent systematic review that TIF appears to provide symptomatic relief with reasonable levels of patient satisfaction at short-term follow-up. However, the authors noted that a well-designed prospective clinical trial is needed to assess the effectiveness and durability of TIF as well as to identify the patient population that will benefit from this procedure. In sum, there is a lack of sufficient controlled data to show that TIF is non-inferior to fundoplication or that the procedure has long-term efficacy. For the reasons provided, the request for TIF with EsophyX device is 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 requested procedure is 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.