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

Summary Reviewer 1

A 48-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/12/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. 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 also add to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the risk of metastasis over five years. Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients undergoing sentinel node sampling. 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 that it can be used to make clinical decisions. Therefore, DecisionDx-Melanoma testing performed on 12/12/17 was not likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 48-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/12/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of the services at issue were unlikely to have altered treatment and surveillance recommendations. In sum, DecisionDx-Melanoma testing performed on 12/12/17 was not likely to have been of greater benefit than other available 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: Insurer Denial Upheld

Summary Reviewer 3

A 48-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/12/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. 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 for melanoma has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing performed on 12/12/17 was not likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 26-year-old male enrollee has requested reimbursement for inpatient hospital services provided from 4/12/18 through 4/17/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that in this case, the patient did not have high-risk features of a headache, including altered mental status, new neurologic deficit or associated seizures. He did not complain of a sudden-onset headache, and he had already been evaluated with multiple computed tomography (CT) scans of the head.  The inpatient admission was not medically necessary. 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. Therefore, inpatient hospital services provided from 4/12/18 through 4/17/18 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 41-year-old female enrollee has requested reimbursement for residential substance use disorder treatment services provided from 8/16/15 through 9/27/15. 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 this patient had a very serious polysubstance addictive illness complicated by the co-occurring diagnoses of generalized anxiety disorder and major depressive disorder in context of enduring characterological issues.  Despite prior treatment interventions, the patient was unable to sustain any meaningful sobriety.  Her substance use dominated all functional domains and necessitated a complicated detoxification.  She had a strained relationship with her significant other and her parents.  Despite her impaired insight, the patient was motivated for treatment. Based on the longitudinal history and medical documentation, the patient would have promptly relapsed and required re-admission in the absence of residential programming. Both the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards. Additionally, the services provided during the disputed timeframe were for active treatment, and 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 services at issue were medically necessary for treatment of the patients behavioral health condition.Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

An 18-year-old female enrollee has requested reimbursement for intensive outpatient program services provided from 4/25/19 through 7/09/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 1 due to no recent suicidal ideation and impulsive behaviors. With regards to functional status, the records support a score of 3 due to problems in interpersonal interaction and missing treatment. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 3 due to overall medical stability with evidence of substance use. With regards to level of stress of the recovery environment, the records support a score of 3 due to a non-sober living environment. In terms of level of support of the recovery environment, the records support a score of 3 due to few supportive resources. With regards to treatment and recovery history, the records support a score of 3 due to some treatment response in the intensive outpatient program treatment but consideration of worsening symptoms. In terms of engagement and recovery status, the records support a score of 3 due to fair cooperation in treatment but limited ability to accept responsibility for recovery. Therefore, the patient has a composite score of 19. This score correlates with high intensity community-based services. This level of care is consistent with intensive outpatient program level of care. Therefore, intensive outpatient program services provided from 4/25/19 through 7/09/19 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 52-year-old male enrollee has requested reimbursement for a wearable cardioverter defibrillator provided on 1/24/19. The Health Insurer has denied this request indicating that the device at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient had a recent myocardial infarction and underwent acute revascularization with coronary stenting. His subsequent ejection fraction was below 35%, and his medical management was being optimized. In this situation, a permanent automatic implantable cardioverter-defibrillator is not indicated until three months have passed after revascularization if the ejection fraction remains less than 35%. However, he was at increased risk for sudden death during this period. Medical therapy was also being optimized to improve left ventricular function during this period. A wearable cardioverter defibrillator can provide temporary protection from early sudden death due to arrhythmia in this patient population during this interim period. The medical evidence supports the device at issue in this clinical setting. Therefore, the wearable cardioverter defibrillator provided on 1/24/19 was likely to have been more effective than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 52-year-old male enrollee has requested reimbursement for a wearable cardioverter defibrillator provided on 1/24/19. The Health Insurer has denied this request indicating that the device at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer found that in this circumstance, there is potential for recovery of left ventricular function over time with medical therapy. There was no documented indication for immediate placement of a defibrillator, such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest.  Placement of a prophylactic defibrillator is not recommended until a period of time greater than 90 days where continued left ventricular dysfunction is documented to persist despite appropriate treatment. A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. Recent retrospective trials in patients with newly diagnosed non-ischemic cardiomyopathy have not demonstrated benefit with prophylactic wearable defibrillators. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. In sum, the wearable cardioverter defibrillator provided on 1/24/19 was not likely to have been superior over other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 52-year-old male enrollee has requested reimbursement for a wearable cardioverter defibrillator provided on 1/24/19. The Health Insurer has denied this request indicating that the device at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer found that documented high risk of sudden cardiac death in patients with severe left ventricular dysfunction has led to the recommendation of implantable cardioverter defibrillators in this group of patients. Current data from multiple trials and registries have advocated the use of a wearable cardioverter defibrillator after an initial diagnosis of severe left ventricular dysfunction with an ejection fraction of less than or equal to 35%. This patients ejection fraction was 25 to 30%. The recommended timing of a wearable cardioverter defibrillator placement based on guidelines from the American College of Cardiology/American Heart Association and the Heart Rhythm Society is within 40 days of an acute myocardial infarction or within 90 days of an initial diagnosis of congestive heart failure with a low ejection fraction. Therefore, the placement of the patients wearable cardioverter defibrillator on 1/24/19 falls within accepted guidelines. Thus, the wearable cardioverter defibrillator provided on 1/24/19 was likely to have been more effective than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 40-year-old female enrollee has requested reimbursement for homocysteine testing and polymerase chain reaction testing for EBV performed on 8/08/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the evaluation for vitamin B12 deficiency includes an examination for gastrointestinal, dermatologic, neurologic, and other findings, and laboratory testing, including a complete blood count and vitamin B12 levels. Additional testing with methylmalonic acid (MMA) or homocysteine levels may be appropriate if the vitamin B12 level is borderline low or discordant with the clinical picture. In this case, do not support the need for homocysteine testing. Therefore, homocysteine testing and polymerase chain reaction testing for Epstein Barr virus performed on 8/08/18 were not likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 40-year-old female enrollee has requested reimbursement for homocysteine testing and polymerase chain reaction testing for EBV performed on 8/08/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the submitted records fails to demonstrate the superior effectiveness of the services at issue. The records do not document a history of homocystinuria, a coagulation disorder such as deep vein thrombosis or pulmonary embolism. The literature does not support the homocysteine level in this setting. With regards to polymerase chain reaction testing for Epstein Barr virus, the records do not document a history of post-transplant lymphoproliferative disorder, lymphoma or an immune compromised state. She has mild liver function elevation that is non-specific. Although Epstein Barr virus antibody testing may have been appropriate, there was no indication for polymerase chain reaction testing. The literature does not support routine use of polymerase chain reaction testing for Epstein Barr virus. In sum, homocysteine testing and polymerase chain reaction testing for Epstein Barr virus performed on 8/08/18 were not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 40-year-old female enrollee has requested reimbursement for homocysteine testing and polymerase chain reaction testing for EBV performed on 8/08/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that Homocysteine has not been found to be a risk factor for cardiovascular disease and should not be ordered as a routine for this purpose. Homocysteine levels may be useful in evaluating patients who are symptomatic of B12 deficiency, but have normal or borderline B12 levels. The medical records do not indicate findings consistent with B12 deficiency, such as macrocytic anemia or psychiatric complaints. It appears that B12 therapy was planned to be continued regardless of homocysteine level results. Thus, homocysteine testing and polymerase chain reaction testing for Epstein Barr virus performed on 8/08/18 were not likely to have been more effective than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 66-year-old male enrollee has requested reimbursement for positron emission tomography (PET) scan performed on 9/06/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees tumor of suprahyoid epiglottis. The physician reviewer found that the medical evidence supports the services at issue in this clinical setting. PET/CT has an important role in the diagnosis and treatment of head and neck cancer. The technique can aid in the detection of an unknown primary tumor, assist in locoregional staging, evaluate for distant metastases or second primary tumors, and be a component of restaging and tumor surveillance. PET/CT is also used for precise delineation of the tumor volume for radiation therapy planning, and for treatment response monitoring, by detecting residual or recurrent disease. This patient was diagnosed with squamous cell carcinoma. The PET scan was medically necessary for staging and treatment planning. Thus, PET scan performed on 9/06/18 was medically necessary for the evaluation of this patient. Therefore, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 30-year-old female with moderate-severe rheumatoid arthritis. The patient has requested authorization and coverage for Enbrel SureClick. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that according to the 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis, in established rheumatoid arthritis, aIf disease activity remains moderate or high despite DMARD monotherapy, the recommendation is to use combination traditional DMARDs or add a tumor necrosis factor inhibitor (TNFi) or a non-TNF biologic or tofacitinib (all choices with or without methotrexate, in no particular order of preference), rather than continuing DMARD monotherapy alone.a In this case, the records document a history of moderate-severe rheumatoid arthritis. In addition, she has failed DMARD therapy. She previously was treated with methotrexate, sulfasalazine and hydroxychloroquine, with uncontrolled disease. It is therefore appropriate to consider TNFi therapy in this case based on the guidelines. She was placed on the TNFi, Humira, which was ineffective. She was then placed on an alternate TNFi, Enbrel SureClick. On 7/29/20, office visit notes indicate that Enbrel SureClick was helping to control rheumatoid arthritis. There is sufficient support for the requested medication in this clinical setting. Therefore, Enbrel SureClick is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 25-year-old male enrollee has requested reimbursement for partial hospitalization program for substance use disorder from 2/17/16 through 6/07/16. 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 the submitted documentation fails to demonstrate the medical necessity for the services at issue.  The patient showed no post-acute withdrawal symptoms.  The records indicated he was maintaining sobriety.  He was not a danger to himself or to others.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. The progress notes indicated that he was containing his anger and irritability. He was using his coping skills.  He was medically and psychiatrically stable. He minimized his addiction. He was more cooperative and engaged. He was working on emotional dysregulation and using his coping skills to self soothe and handle stress.  He denied suicidal or homicidal ideation. His parents were supportive. He could have been treated at a lower level of care by 2/17/16. Therefore, the structured 24-hour setting of residential treatment, from 2/17/16 through 6/07/16, was not medically necessary.  For the reasons stated above, 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: Insurer Denial Overturned

Summary Reviewer 1

The patient is a 24-year-old female with a history of both palmar and plantar severe hyperhidrosis.  Her condition has been refractory to medical therapy.  The patient has had thorascopic sympathectomy which resolved the palmar hyperhidrosis, but she has persistent plantar symptomatology that has caused significant lifestyle and medical issues.  The patient has requested reimbursement and prospective authorization and coverage for sympathectomy performed by an out-of-network provider from 2/09/17 through 5/10/17.  The Health Insurer has denied this request and reported that the services at issue were and are investigational for the treatment of this patient. The medical evidence supports the services at issue in this clinical setting.  This patient has failed conservative medical therapy.  The requested procedure has been discussed in the peer-reviewed literature and has been shown to have efficacy for the treatment of this patients condition.  All told, sympathectomy performed by an out-of-network provider from 2/09/17 through 5/10/17 was and is likely to be more effective than other treatment options. Based upon the information set forth above, the services at issue were and 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.