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

Summary Reviewer 1

A 61-year-old female enrollee has requested reimbursement of collagen crosslinking test (CPT 82523) performed on 9/07/18. 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 Osteoporosis is a condition of thinning of the bones which leads to increased risk of fracture. Bone mineral density assessment, via DEXA, is the standard for evaluation and diagnosis of osteoporosis. Since changes in bone mass and density in response to antiresorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover may be a useful adjunct in monitoring of osteoporotic patients treated with antiresorptive agents. The medical evidence suggests that biochemical markers may assist in making therapeutic decisions. In general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine. There is sufficient support for the services at issue in this clinical setting. Therefore, collagen crosslinking test (CPT 82523) performed on 9/07/18 was likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 61-year-old female enrollee has requested reimbursement of collagen crosslinking test (CPT 82523) performed on 9/07/18. 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 bone turnover marker assays measure collagen breakdown products released from osteoclasts and osteoblasts during the process of bone resorption and formation. Measurement of bone turnover markers is complicated by large random within-patient variability, biologic variability (age, gender, body mass index, circadian, and menstrual variation), and poor standardization of most assays. Uncertainties over its clinical use can be in part resolved by adopting international reference standards, which do not exist at this time. Guideline committees typically recommend against routine use of bone turnover markers, due to the limitations of measuring and interpreting bone turnover markers in individual patients. There is a lack of prospective trials to define the most optimal approach for incorporating bone turnover markers into the management of patients with osteoporosis. In sum, collagen crosslinking test (CPT 82523) performed on 9/07/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 61-year-old female enrollee has requested reimbursement of collagen crosslinking test (CPT 82523) performed on 9/07/18. 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 documentation supports the superior efficacy of the services at issue. Reginster and colleagues noted that there are consistent data showing that short-term changes in biochemical markers of bone turnover may be significant predictors of future changes in bone mineral density or fracture reduction, hence suggesting that bone turnover markers play a significant role in the monitoring of anti-osteoporosis therapy. The use of markers of bone turnover is standard practice among endocrinologists and other specialists in osteoporosis. It is used as a guide to monitor compliance and efficacy of treatment. It also helps to identify non-responders that require additional work-up for other causes of osteoporosis. Thus, collagen crosslinking test (CPT 82523) performed on 9/07/18 was likely to have been more effective than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 67-year-old male enrollee has requested reimbursement for clonoSEQ assay test performed on 9/13/20. 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 per the National Comprehensive Cancer Network guidelines, aEarly referral for high-dose therapy with stem cell rescue is advisable for planning purposes.a Achievement of minimal residual disease (MRD) negativity is associated with improved clinical response. The amount of MRD also guides eligibility for autologous transplant and clinical trials. Multiple studies currently recruiting for mantle cell lymphoma require measurement of MRD to determine eligibility for enrollment. There is sufficient evidence for the services at issue in this clinical setting. Therefore, clonoSEQ assay test performed on 9/13/20 was likely to have been more beneficial for the evaluation of the patient than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 67-year-old male enrollee has requested reimbursement for clonoSEQ assay test performed on 9/13/20. 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 the current medical evidence has not established the superior efficacy of the services at issue. The assay has been shown to be useful in determining MRD in several types of hematologic malignancies. However, it has not been shown to be clinically beneficial in decision making for mantle cell lymphoma. The oncologist who saw him in September 2020 commented on a clinical trial looking at whether clonoSEQ would be useful in this situation, but there is no clear data yet as to its usefulness. Therefore, clonoSEQ assay test performed on 9/13/20 was not likely to have been more beneficial for the evaluation of the patient than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 67-year-old male enrollee has requested reimbursement for clonoSEQ assay test performed on 9/13/20. 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 the patient had B-cell clonality, otherwise known as B-cell receptor gene rearrangement analysis, for diagnostic purposes. According to the National Comprehensive Cancer Network guidelines, the initial diagnosis of any B-cell non-Hodgkin lymphoma routinely involves, aImmunohistochemistry, flow cytometry, molecular analysis to detect B-cell receptor (PCR) and T-cell receptor (TCR) gene rearrangements, karyotype or FISH for major translocations.a In this case, the technique to detect the B-cell receptor rearrangement was next generation sequencing.  The goal is to detect a gene rearrangement establishing clonality and B-cell origin for the neoplastic cells. Additionally, subtyping mantle cell lymphoma immunoglobulin heavy chain variable gene sequencing can aid in subtyping the neoplasms. Therefore, clonoSEQ assay test performed on 9/13/20 was likely to have been more beneficial for the evaluation of the patient than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 53-year-old female enrollee has requested authorization and coverage for fenofibric acid DR. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hypertriglyceridemia. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. This patient has a history of Crohns disease, severe hypertriglyceridemia leading to pancreatitis and documented intolerance/ineffectiveness to several medications including fenofibrate at doses ranging from 48 mg to 145 mg. She is now tolerating a related medication (fenofibric acid 135 mg DR) that is also effective at lowering triglyceride levels. Her condition is life-threatening. Thus, it would be unsafe to trial the fenofibrate doses on the Health Insurers preferred formulary. In addition, there is improved bioavailability with the patients current fenofibric acid medication that may be important given her partial small bowel resection and colectomy. In summary, given the patients life threatening condition, trials and intolerance/ineffectiveness of several fenofibrates, stability and effectiveness on current medication and potential advantages of her current medication over formulary alternatives, the requested fenofibric acid DR is medically necessary 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: Insurer Denial Overturned

Summary Reviewer 




The parent of a 16-year-old female enrollee has requested reimbursement for mental health residential treatment center services from 11/17/16 through 12/10/16. 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 that there is sufficient support in the records for the medical necessity of the services at issue in this clinical setting.  Evidence-based assessments are indispensable in determining necessary level of care for children, to insure their level of care meets their individual needs at the least restrictive setting possible. The medical literature states that children should be treated in the setting that is least restrictive and disruptive to their lives. More restrictive facilities, like inpatient or residential treatment, are indicated in emergencies or when patients are not responding to efforts at outpatient treatment. In this patients case, her psychosis had not resolved despite a medical hospital stay, followed by almost three weeks of psychiatric hospital stay and a weeklong PHP stay. The records indicate that this patient had failed the PHP directly prior to her RTC admission. The American Academy of Child and Adolescent Psychiatry recommends that children and adolescents be treated in the least restrictive setting possible to maintain and foster natural supports. This patient did not appear to have adequate treatment progress, and it would not have been safe to treat the patient in a less restrictive setting. The RTC was likely the least restrictive safe setting for this patient after having failed the PHP. Therefore, the mental health residential treatment center services from 11/17/16 through 12/10/16 were medically necessary for treatment of this patients medical condition. Therefore, for the reasons stated above, 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 Upheld

Summary Reviewer 


A 56-year-old male enrollee has requested authorization and coverage for uvulopalatopharyngoplasty for obstructive sleep apnea.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has mild obstructive sleep apnea and snoring.  It is noted that his obstructive sleep apnea is severe when in the supine position.  There is no documentation of retropalatal obstruction or of redundant palatal soft tissue.  While uvulopalatopharyngoplasty is a common surgical procedure for treatment of obstructive sleep apnea, its success rate as a stand-alone surgery is low.  Its success rate in conjunction with nasal surgery is not much greater.  The fact that apnea-hypopnea index is greater when in the supine position does not determine that there is retropalatal airway obstruction.  All told, the requested uvulopalatopharyngoplasty is not medically indicated for the treatment of this patient.  Therefore, the requested services are 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

A 60-year-old female enrollee has requested reimbursement for gene tests performed on 6/09/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees non-small cell lung cancer. The physician reviewer found that for patients with adenocarcinoma, there is clinical value in testing the tissue for certain mutations. In this patients case, apparently her liver biopsy was positive for an epidermal growth factor receptor (EGFR) exon 19 mutation. Therefore, this indicated that Tarceva might be useful. When patients on Tarceva progress, it is valuable to test for a further EGFR mutation (T790M) by a blood test, such as Guardant. If this new mutation is present, there is a treatment directed at that (Tagrisso). However, testing for a wide variety of other mutations is currently not clinically beneficial, as it has not been demonstrated that giving a treatment directed at a target found in that way is an improvement over giving a treatment based on the clinicians judgment. Finding a mutation does not guarantee that a drug directed at that target will be efficacious. All told, testing for T790M alone was likely to have been more efficacious than other methods of evaluating this patient. However, the superior efficacy of the remaining of the services at issue has not been established. Based upon the information set forth above, a portion of the services 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 partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 60-year-old female enrollee has requested reimbursement for gene tests performed on 6/09/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees non-small cell lung cancer. The physician reviewer found that molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer.  Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. In sum, gene tests performed on 6/09/16 were likely to be more beneficial than other methods of evaluating this patient. Based upon the information set forth above, the services 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

A 60-year-old female enrollee has requested reimbursement for gene tests performed on 6/09/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees non-small cell lung cancer. The physician reviewer found that the therapy of advanced non-small cell lung cancer has been revolutionized by the finding of epidermal growth factor (EGFR) mutations in certain adenocarcinomas. The mutations are more common in those who have never smoked.  Even if stage IV disease is present, therapy targeted to EGFR with erlotinib results in prolonged survival when compared with standard chemotherapy regimens. The mutational landscape of non-small cell lung cancer has significantly expanded in the past two to three years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. Generally, KRAS, TP53, and BRAF are included in these panels and are informative. KRAS and EGFR mutations are usually mutually exclusive, so a sample with KRAS mutation does not need to be further analyzed for EGFR mutation. Patients on targeted therapy do develop resistance to erlotinib, and this too may be appreciated at the genetic level by recognition of new mutations or amplifications in parallel signal transduction pathways. BRAF mutations may suggest alternative targeted therapies that may be better than those selected empirically. ALK mutation or rearrangement is present in another subset of non-small cell lung cancer that may be amenable to targeted therapy with crizotinib. The medical evidence supports the services at issue in this patients case. Thus, gene tests performed on 6/09/16 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 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 54-year-old female enrollee has requested reimbursement and prospective authorization and coverage for Perjeta and Herceptin combination from 9/08/15 forward.  The Health Insurer has denied this request indicating that the medications at issue were not and are not medically indicated for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication combination.  Perjeta is a monoclonal antibody which targets the HER2 positive breast cancer cells, similar to, but not exactly in the same way, as Herceptin.  In metastatic breast cancer, when used in combination with Herceptin and Taxotere, Perjeta yields superior progression-free survival compared to treatment with Taxotere and Herceptin without Perjeta.  Combining Perjeta with Herceptin and chemotherapy also appears superior in the neoadjuvant setting.  However, there is a lack of data supporting the use of combined Herceptin and Perjeta in the adjuvant setting.  At this time, the current medical evidence has not established the medical necessity of the requested medication combination in this clinical setting.  All told, Perjeta and Herceptin combination from 9/08/15 forward were not and are not medically indicated for the treatment of this patient.  Therefore, the medications at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 50-year-old male has requested authorization and coverage for code 43210 and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested services in this patients case. The submitted records do not document that this patients gastroesophageal reflux disease is advanced and do not demonstrate good correlation of symptoms with acid reflux events. Transoral incisionless fundoplication (TIF procedure) has shown durable response for some patients with gastroesophageal reflux disease. However, in this patients case there is a lack of documentation of esophagitis, intolerance to proton pump inhibitor therapy, or a trial of maximized acid suppression treatment. Available records do not support that gastroesophageal reflux disease has been objectively demonstrated by pH testing. The records support that dyspepsia improved after Helicobacter pylori eradication and with lifestyle modification, even in the absence of proton pump inhibitor treatment. Therefore, code 43210 and one inpatient bed day are not likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 50-year-old male has requested authorization and coverage for code 43210 and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. This patient does not have pathologic acid reflux by testing, and the records do not support a reflux operation or procedure. Transoral incisionless fundoplication (TIF) is an endoscopic procedure performed under general anesthesia. TIF can be performed in patients with typical gastroesophageal reflux disease symptoms, no or only low-grade erosive esophagitis (grades A and B), and no or only small hiatal hernia (less than or equal to 2 cm). Although TIF is associated with fewer postoperative adverse effects, such as gas, bloating and dysphagia, compared with surgery fundoplication, the durability of TIF is less than that of surgery. Huang and colleagues performed a meta-analysis of five randomized trials and 13 prospective studies. The authors noted that proton pump inhibitor use after TIF increased over time, and the satisfaction rate was only 69.15% at six months. In sum, code 43210 and one inpatient bed day are not likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 50-year-old male has requested authorization and coverage for code 43210 and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the efficacy of transoral incisionless fundoplication (TIF) using the EsophyX device has been studied in randomized controlled trials. However, the conclusions are contradictory. The large randomized trial by Witteman and colleagues included 60 patients. The authors found no improvement in esophageal acid exposure compared with baseline at 12 months. Normalization of pH was accomplished in only 29% in conjunction with deteriorated valve appearances at endoscopy and resumption of proton pump inhibitors in 61%. The study concluded that no long-term objective reflux control was achieved. A recent meta-analysis by McCarty and colleagues noted that further safety and efficacy comparison is needed with conventional treatment, such as Nissen fundoplication. There have been reports of severe adverse events during the procedure and the need for surgery to revise ineffective TIF. Thus, code 43210 and one inpatient bed day are not likely to be more beneficial than other available treatment options.