Persius/hicric huggingface dataset:
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 31-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/11/19. 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 melanoma based on the five-year risk of metastasis. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma class, in patients who had undergone sentinel node biopsy. However, 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 prospectively to make clinical decisions. National Comprehensive Cancer Network guidelines do not recommend the services at issue in this clinical setting. Therefore, DecisionDx-Melanoma testing performed on 12/11/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 31-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/11/19. 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 this patient had an early stage melanoma. Commercially available gene expression profiling (GEP) tests are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear whether these tests provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariable nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. Newer prognostic molecular techniques should not replace standard staging procedures.  There is a lack of 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. All told, DecisionDx-Melanoma testing performed on 12/11/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 31-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/11/19. 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 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 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 the 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. This was also the consensus opinion of the National Comprehensive Cancer Network guidelines. Thus, DecisionDx-Melanoma testing performed on 12/11/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 50-year-old female enrollee has requested reimbursement for residential substance abuse rehabilitation services provided from 7/25/14 through 8/23/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found upon review of the submitted documentation the medical necessity of residential treatment services provided from 7/25/14 through 8/23/14 has not been established. In this case, the patient was motivated to seek alternative options to treatment in order to reduce her recently prescribed sedating medications. According to the records, although the relationship dynamics were strained, the patient had a safe residence and supportive family. Her physical examination upon presentation was reassuring and her provider determined that detoxification was not necessary. She was seeing a psychiatrist in the community. The patient had no history of suicidality and the diagnosis of bipolar illness was not substantiated in the records provided. Further, the records do not demonstrate the patient had failed a less restrictive treatment setting, such as partial hospitalization or an intensive outpatient program, during the episode of illness. This is significant in this case for two reasons: first, current psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment; second, there was no evidence to suggest that a less restrictive treatment setting would have been insufficient. Based upon the submitted records and accepted principles of psychiatric practice, the residential rehabilitation services at issue were not medically necessary for treatment of the patients behavioral health condition.  The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 20-year-old male without a significant past medical history who presented to the emergency room with complaints of bilateral arm pain after lifting weights.  He presented from an urgent care. At the time of presentation to the emergency department, his vital signs were stable. The physician reviewer found that at the time of admission, the patient was hemodynamically stable and afebrile with normal oxygen saturations on room air. He was diagnosed with rhabdomyolysis without acute kidney injury or any significant electrolyte disturbances. The inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patientas 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. Therefore, inpatient admission provided from 9/23/19 through 9/26/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The parent of a 16-year-old male enrollee has requested authorization and coverage for Humatrope 24 mg cartridge. 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 did not meet generally accepted diagnostic criteria for idiopathic short stature because his height has been above -2.25 standard deviations. This patient was not growth hormone deficient based on normal growth hormone responses to two provocative tests, normal IGF-1, and normal IGFBP-3 on 10/28/15. Standard of care for suspected growth disorders includes direct height measurements of both biologic parents whenever possible, since self-reported histories can be unreliable. Based on the patients recent bone age of 14 to 15 years, height 62.91, testosterone of 323.2 ng/dL and Tanner stage IV development, he is likely to attain at least his mid-parental target height of 64.5.  His growth pattern, mildly delayed bone age before puberty, and mildly delayed pubertal onset are most consistent with normal variations of pubertal timing. There is a lack of support for the requested medication in this clinical setting. Therefore, Humatrope 24 mg cartridge is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 50-year-old female has requested authorization and coverage for sacroiliac joint fusion.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the International Society for Advancement of Spine Surgery (ISASS) policy statement for minimally invasive sacroiliac joint fusion provides specific indications for surgery. Criteria include: significant sacroiliac joint pain or significant limitations in activities of daily living because of sacroiliac joint pain; sacroiliac joint pain confirmed by at least three positive sacroiliac joint provocative tests; confirmation of the sacroiliac joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular sacroiliac joint block in the immediate post-injection period; failure to respond to at least six months of non-surgical treatment including medications, rest, physical therapy, and sacroiliac joint steroid injection or rhizotomy; and, additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been clearly considered, investigated and ruled out. This patient presents with a long history of axial low back and bilateral sacroiliac joint pain which is reported as severely debilitating.  She has been diagnosed with sacroiliac arthropathy.  She reported a remote history of trauma.  Clinical examination findings are generally consistent with sacroiliac joint pathology with positive compression and distraction tests, but do not document three positive examination findings consistent with evidence-based medical guidelines.  There is a lack of imaging findings documented relative to the right sacroiliac joint that confirm sacroiliitis due to spondyloarthropathy.  Thus, the medical evidence does not support the requested services in this clinical setting.  Therefore, the requested sacroiliac joint fusion is not likely to be more effective 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: Insurer Denial Upheld

Summary Reviewer 2


A 50-year-old female has requested authorization and coverage for sacroiliac joint fusion.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the superior efficacy of the requested services.  This patients history supports a diagnosis of complex regional lumbosacral pain syndrome with multiple pain generators.  Her history suggests likely pain generation from intervertebral disc and facet joints.  The reliance of steroid local injection into the sacroiliac joint is not sufficient to localize pain generation from the sacroiliac joint in the face of multifactorial chronic pain.  Many patients experiencing chronic inflammation at the sacroiliac joint have minimal symptoms.  The study by Wise and colleagues is a prospective cohort study with limited number of patients.   The study is not blinded as to procedure and is vulnerable to selection bias, evaluation bias and placebo effect.  In the article by Schoell and colleagues, the authors identified 469 patients who had undergone minimally invasive sacroiliac fusion between 2007 and 2014.  Overall complication rates were 13.2% at 90 days after surgery and 16.4% at six months after surgery.  The authors concluded that minimally invasive sacroiliac joint fusion could possibly carry higher risks of complications than had been previously stated.  In sum, the requested sacroiliac joint fusion is not likely to be more efficacious 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: Insurer Denial Upheld

Summary Reviewer 3


A 50-year-old female has requested authorization and coverage for sacroiliac joint fusion.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is sufficient support for the requested services in this clinical setting.  Polly and colleagues performed a randomized controlled trial comparing minimally invasive sacroiliac joint fusion using triangular titanium implants to nonsurgical treatment at 12 months.  A total of 148 patients with sacroiliac joint dysfunction were randomly assigned to minimally invasive sacroiliac joint fusion with triangular titanium implants or nonsurgical treatment.  The conclusion was that this level one study showed that minimally invasive sacroiliac joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with sacroiliac joint dysfunction caused by degenerative sacroiliitis or sacroiliac joint disruptions.  Pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment.  Based upon a review of the literature, the requested sacroiliac joint fusion is likely to be more effective than other treatment options.  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: Insurer Denial Overturned

Summary Reviewer 

This patient is a 45-year-old male with history of major depressive disorder. The patient has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation provided from 8/12/20 forward. 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 this patient. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. This patient has had prior trials of two antidepressants. He has also been in weekly CBT since 2015, and this has also been ineffective. For patients with major depression that does not respond to initial treatment with an antidepressant and who decide to switch treatment, another reasonable option is repetitive transcranial magnetic stimulation. Meta-analysis of randomized trials that compared transcranial magnetic stimulation with sham treatment indicate that transcranial magnetic stimulation can be efficacious for acute treatment-resistant depression. Repetitive transcranial magnetic stimulation is indicated for patients with unipolar depression who have failed at least one antidepressant medication. Use of repetitive transcranial magnetic stimulation for treatment-resistant depression is consistent with treatment guidelines from the American Psychiatric Association. Therefore, transcranial magnetic stimulation provided from 8/12/20 forward was and is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 45-year-old male who has been diagnosed with psoriasis with total body surface area of greater than 10%, severely affecting his quality of life. He has tried and failed various topical therapies as well as phototherapy. The physician reviewer found that Psoriasis is a chronic inflammatory skin disease. Patients typically present with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. The long-term use of traditional systemic therapies is frequently unacceptable because of renal, hepatic, pulmonary toxicity and limited efficacy. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities.
The U.S. Food and Drug Administration has approved secukinumab (Cosentyx) to treat adults with moderate-to-severe plaque psoriasis. In clinical trials, subcutaneous secukinumab was more effective than placebo, etanercept and ustekinumab at improving psoriasis symptoms (with high skin clearance). Secukinumab was more effective than placebo in studies specifically investigating efficacy in the difficult-to-treat palmoplantar and nail psoriasis populations. Studies specifically
investigating drug efficacy in these populations are rare, and treatment options for these patients are limited. Therefore, Cosentyx 300 mg dose, two pens are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The parent of an eight-year-old male enrollee has requested reimbursement for FirstStep Dx Plus testing performed on 5/28/14.  The Health Insurer has denied this request indicating that the testing at issue is considered investigational for the treatment of the enrollees autism spectrum disorder (ASD). The physician reviewer found the testing at issue was likely to be more effective for this patient than other available treatment options. Chromosomal microarray analysis (CMA) is recommended by the American College of Medical Genetics (ACMG) as a first-tier test for patients with ASD (Manning and Hudgins). The yield of CMA in patients with ASD is estimated to be around 10 percent. While findings on CMA may not alter treatment of ASD features themselves in all patients, CMA has become the standard of care for diagnosis in patients with ASD. Increasing numbers of patients with ASD have been found to have underlying copy number variations. As such, it is possible that some copy number variations have also been associated with specific neuropsychological treatments or medications that have been shown to be more efficacious in patients with ASD due to that underlying cause. Additionally, copy number variations on CMA may inform about possible other complications and medical risks, some of which can be screened for and treated. For the reasons provided, FirstStep Dx Plus testing performed on 5/28/14 was 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 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: Insurer Denial Overturned

Summary Reviewer 2

The parent of an eight-year-old male enrollee has requested reimbursement for FirstStep Dx Plus testing performed on 5/28/14.  The Health Insurer has denied this request indicating that the testing at issue is considered investigational for the treatment of the enrollees autism spectrum disorder (ASD). The physician reviewer found the FirstStep Dx Plus testing performed on 5/28/14 was likely to be more effective for this patient with autism than other available treatment options. CMA testing is the first-line genetic testing when there are findings suggesting an underlying genetic etiology. The medical literature demonstrates that this test has become an important and mainstream tool in the practice of clinical genetics. The study by Henderson and colleagues retrospectively reviewed the medical records of patients who had abnormal chromosomal microarray findings reported per laboratory over a three-year period and quantified the management recommendations made in response to these results. The authors concluded that These results empirically demonstrate the clinical utility of chromosomal microarray by providing evidence that management was directly affected for the majority of patients in our cohort with abnormal chromosomal microarray findings. Based on the support in the medical literature, the testing at issue was 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 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: Insurer Denial Overturned

Summary Reviewer 3


The parent of an eight-year-old male enrollee has requested reimbursement for FirstStep Dx Plus testing performed on 5/28/14.  The Health Insurer has denied this request indicating that the testing at issue is considered investigational for the treatment of the enrollees autism spectrum disorder (ASD). The physician reviewer found the clinical literature supports CMA as a primary screening test for autistic children (Miller, et al; Manning and Hudgins). The article by McGrew and colleagues concluded that CMA should be the clinical standard in all specialties for first tier genetic testing in ASD. In addition, this patient has additional factors to validate the need for the CMA testing.  He carries the dual diagnoses of autism and ADD, which also suggests a multi-factorial genetic etiology. CMA is a routine part of the evaluation of an autistic child, whether or not the child is intellectually disabled or if dysmorphic features are noted (Miller, et al). In sum, the testing at issue was 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 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.