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

Summary Reviewer 


A 53-year-old female enrollee has requested has requested authorization and coverage for Sovaldi and Daklinza. The Health Insurer has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of the fibrosis stage.  In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks. This is based on the ALLY-3 study, which showed a cure rate of 97% (Nelson, et al; Hezode, et al). Delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, treatment with Sovaldi and Daklinza is medically necessary for the treatment of this patients hepatitis C infection. Therefore, the requested medications are 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 54-year-old male enrollee has requested reimbursement for inpatient admission on 6/3/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees lower abdominal pain. The physician reviewer found that impatient care is medically 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. Outpatient observation admission is appropriate when the provider is unsure about the patients need for inpatient admission and requires time for short-term treatment, assessment, and reassessment in order to make that decision or the physician anticipates that the patients condition can be evaluated and treated within 24 hours and/or rapid improvement of the patients condition can be anticipated within 24 hours. In this case, the patient was admitted in stable condition and could have been treated at an observational level of care.  He was tolerating oral fluids and his pain was well controlled. The patient remained hemodynamically stable without a need for any urgent procedures. Thus, the patient could have been treated at a lower level of care. As such, the inpatient admission on 6/3/16 was not medically necessary for treatment of the patients medical condition. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 34-year-old male enrollee has requested authorization and coverage for Bicillin L-A. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition.  the physician reviewer found THE requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard. The patient does not have clinically documented late stage Lyme disease either in the form of Lyme arthritis or neuroborreliosis. Tremor alone is not a finding in late stage Lyme disease. In addition, the patient does not have laboratory results documenting late stage Lyme. There is no IgG positive titer or positive cerebrospinal fluid or synovial fluid results. There is no joint effusion and no neurologic deficits documented. Moreover, the treatment of late stage Lyme disease, if established, is a four-week course of intravenous ceftriaxone. Long courses or repeat courses of antibiotic have not demonstrated efficacy in multiple trials. In sum, there is a lack of documentation supporting a diagnosis of late stage Lyme disease. Therefore, the requested medication 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 medication 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.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


A 34-year-old male enrollee has requested authorization and coverage for Bicillin L-A. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition.  The physician reviewer found the patient is a 34-year-old male who has been diagnosed with persistent Lyme disease. He had a positive IgM Western blot for Lyme with a negative IgG western blot for Lyme on 3/28/13. There is no further laboratory testing submitted to support a diagnosis of secondary, tertiary or chronic Lyme or neuroborreliosis. An office visit note dated 9/9/15 indicates that the patient reports doing better in general and marked improvement with starting Bicillin. The patient reports improved strength, less tremor/shaking and improvement in cognitive function. The assessments are listed as Lyme disease, anxiety state, attention or concentration deficit, malaise, fatigue, myalgia and myositis, headache, bartonellosis, candidiasis of mouth and disturbance of skin sensation. In the patients appeal letter, he states that has been using Bicillin L-A since July 2015 and has improved shaking and vibrating, more energy, less tingling, trouble walking, memory and nerve problems and more. The patient has requested authorization and coverage for Bicillin L-A. The Health Insurer has denied this request as investigational. 

Based on the documentation submitted for review, there is a lack of evidence demonstrating the patient has chronic Lyme disease. The laboratory data shows that he may have had acute or early Lyme in September 2013, but no evidence of ongoing infection is submitted. In the absence of evidence of ongoing infection with Borrelia or any other tick born disease, antibiotic treatment is less likely to be of benefit. In addition, the Infectious Diseases Society of America (IDSA) guidelines report that long term antibiotic treatment does not improve the outcome in patients suffering from Lyme, post Lyme or chronic Lyme. Thus, continued use of antibiotics beyond a month without evidence of ongoing infection cannot be justified. Given the above, Bicillin L-A 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 medication 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.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 34-year-old male enrollee has requested authorization and coverage for Bicillin L-A. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition.  The physician reviewer found Bicillin is a long acting form of penicillin G which generates protracted low levels of penicillin in the blood and has been used primarily for the treatment and prevention of streptococcal infections. It has also been used in the therapy of syphilis and related spirochetal infections. However, there is a lack of published medical literature that supports the use of this drug in the treatment of Lyme disease. Moreover, it is not a recommended therapy per the Infectious Diseases Society of America guidelines (Wormser, et al). Therefore, the use of Bicillin L-A 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 medication 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.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 8/30/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas 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 add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individualas melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma class, in patients who had had sentinel node biopsy. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not known if the DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, DecisionDx-Melanoma testing provided on 8/30/19 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 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 8/30/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas melanoma. The physician reviewer found that this patient has 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. Thus, DecisionDx-Melanoma testing provided on 8/30/19 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 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 8/30/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas 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 to 1.0 mm. Metastases to regional lymph nodes may be amenable to excision but they suggest a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on 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. All told, DecisionDx-Melanoma testing provided on 8/30/19 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 

The patient is a 40-year-old female with a history of breast cancer. On 7/01/19, she underwent a bilateral mastectomy with bilateral deep inferior epigastric perforator (DIEP) flap reconstruction. The physician reviewer found that the DIEP flap was for breast reconstruction and was medically necessary. However, the service in dispute in this case is code 15734. Code 15734 describes muscle, myocutaneous, or fasciocutaneous flap, trunk. This code is used in the setting of ventral hernia repair or for repair of wide diastasis recti. The medical records do not support this code in this patientas case. Based on the submitted medical records, there was no ventral hernia repair or repair of wide diastasis recti reported. Per the submitted records, no abdominal weakness or hernia was reported as being present to require a separation of parts repair. Therefore, 15734-59-62 and 15734-62 performed on 7/01/19 were not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 28-year-old female enrollee has requested reimbursement for computer-aided detection performed on 4/20/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has BRCA2 gene mutation. The physician reviewer found that there is sufficient support for the services at issue in this patients case. In young females, breast tissue is almost always mammographically dense, which limits the utility of mammography. MRI is the procedure of choice for annual screening in these patients due to the high sensitivity of the test for breast cancer. Mammography also is of use beginning at age 30, and annual examination with both modalities is recommended at that age. Per the medical evidence, computer-aided detection performed on 4/20/18 was 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 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

A 28-year-old female enrollee has requested reimbursement for computer-aided detection performed on 4/20/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has BRCA2 gene mutation. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The Health Insurer is covering the breast MRI with contrast performed on 4/20/18, consistent with accepted medical practice for female patients with the BRCA2 mutation.  There is a lack of peer-reviewed literature supporting better outcomes when computer-aided detection is added to breast MRI in screening for patients with increased risk of breast cancer. Thus, computer-aided detection performed on 4/20/18 was not likely to have been more efficacious 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 Overturned

Summary Reviewer 3

A 28-year-old female enrollee has requested reimbursement for computer-aided detection performed on 4/20/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has BRCA2 gene mutation. The physician reviewer found that contrast-enhanced breast MRI is approximately 90% sensitive for the detection of breast cancer in the high risk population, whereas ultrasound and mammography are approximately 38% sensitive individually in this population. Computer-aided detection is software that is used as part of the interpretation of the MRI, which helps to analyze the breast tissue and possible abnormalities. It is considered an integral part of the breast MRI examination. Screening contrast-enhanced breast MRI beginning at age 25 is recommended in women with BRCA gene mutations, their untested first degree relatives, and women with a lifetime risk of greater than 20%. MRI with mammography is recommended starting at age 30. This patient has a known BRCA2 gene mutation, which is considered one of the highest risk populations for breast cancer. In this setting, the medical evidence supports annual screening MRI examinations including computer-aided detection. Thus, computer-aided detection performed on 4/20/18 was 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 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 1

The patient is a 17-year-old female with migraine headaches, postural orthostatic tachycardia syndrome, and significantly elevated lactate. Her headaches have been treated with several medications, with some reduction in pain, but she continues to miss school for the associated symptoms of nausea and dizziness. Her provider suspected a mitochondrial disorder and ordered mitochondrial DNA sequencing. The Health Insurer has denied reimbursement for genetic testing (mitochondrial genome sequencing) performed on 12/31/16. Per the Health Insurer, the services at issue were investigational for the evaluation of this patient.  There is sufficient support for the services at issue in this clinical setting. Mitochondrial disorders are challenging to diagnose because they can present at any age, have a wide spectrum of clinical symptoms, and are often insidious in onset.  Because energy production is a need of all tissues, mitochondrial disease can present with virtually any symptom. While there are some well-described mitochondrial syndromes, many patients with mitochondrial disease do not fall neatly into one of the described syndromes.  The advent of mitochondrial genome sequencing and whole exome sequencing have obviated the need for invasive testing, such as muscle biopsy. Patients with mitochondrial disease need comprehensive multidisciplinary care, optimally through a mitochondrial specialty center. There are consensus-based guidelines for treatment and surveillance of these multisystem disorders. In order to determine whether these recommendations should be applied to the patient, a diagnostic evaluation is needed to determine whether a mitochondrial disorder is responsible for the patients symptoms. Mitochondrial genome sequencing is an integral part of such a diagnostic evaluation, and is standard of care for the evaluation of mitochondrial disorders. Therefore, genetic testing (mitochondrial genome sequencing) performed on 12/31/16 was 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 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 patient is a 17-year-old female with a medical history significant for daily migraine headaches refractory to standard outpatient management, periods of nausea and dizziness, and a diagnosis of postural orthostatic tachycardia syndrome (POTS). The records documented concern for an underlying mitochondrial disorder as the unifying diagnosis for her complex symptomatology. Thus, mitochondrial genome sequencing was ordered and performed. The Health Insurer has denied reimbursement for genetic testing (mitochondrial genome sequencing) performed on 12/31/16. Per the Health Insurer, the services at issue were investigational for the evaluation of this patient.  Mitochondria are responsible for cellular energy production in nucleated cells. Dysfunction may occur as a result of defects in either mitochondrial DNA or nuclear mitochondrial genes, and resulting disease may present in either adulthood or childhood. Symptoms may affect one organ or may involve multiple systems. While there is no cure for mitochondrial disease at present, genetic diagnosis is essential for guiding supportive care, as well as providing counselling to families and the patient. Next generation sequencing techniques have been invaluable in diagnosing patients with clinical findings suggestive of mitochondrial disease. In this patients case, she has numerous clinical and biochemical abnormalities that have raised the question of mitochondrial disorder. The information provided by next generation sequencing was important for guiding her future care. In sum, genetic testing (mitochondrial genome sequencing) performed on 12/31/16 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 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: Insurer Denial Overturned

Summary Reviewer 3

The patient is a 17-year-old female with a history of migraines and postural orthostatic tachycardia syndrome. The provider noted that the patient has a constellation of multisystem involvement consistent with a diffuse metabolic disorder with abnormal lactate and pyruvate levels. The records document that a mitochondrial disorder was considered. The provider noted that that establishing a diagnosis was important because management would be altered. The Health Insurer has denied reimbursement for genetic testing (mitochondrial genome sequencing) performed on 12/31/16. Per the Health Insurer, the services at issue were investigational for the evaluation of this patient.  Molecular genetic diagnostic testing for mitochondrial disease has evolved continually since the first genetic basis for a clinical mitochondrial disease syndrome was identified in the late 1980s. Diagnosis via genetic testing for mitochondrial disease involves newer technologies and are the new gold standard methodology for mitochondrial DNA genome sequencing. In the absence of clear-cut genotype-phenotype correlations, biochemical analyses are the cornerstone of the diagnosis of this condition. In this case, the clinical picture was consistent with a mitochondrial DNA disorder. Thus, the services at issue were appropriate in this setting. In sum, genetic testing (mitochondrial genome sequencing) performed on 12/31/16 was 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 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.