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

Summary Reviewer 1

A 42-year-old female enrollee has requested reimbursement for gene test FoundationOne (procedure codes 81201, 81210, 81211, 81235, 81270, 81275, 81292, 81295, 81298 and 81321) on 4/6/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees metastatic breast cancer to the liver and bones. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting.  FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the clinician as to which chemotherapeutic drug would be useful. However, there is no convincing evidence that the assay adds to the decision-making ability of the clinician, nor yields a result that is reliably clinically beneficial. There are various non-randomized studies exploring the value of molecular profiling but these studies are not convincing.  A recent randomized study by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular targets. All told, gene test FoundationOne (procedure codes 81201, 81210, 81211, 81235, 81270, 81275, 81292, 81295, 81298 and 81321) performed on 4/6/16 was not likely to have been more efficacious than other methods of evaluating this patient.  Therefore, for the reasons stated above, the services at issue were not likely to have been 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 42-year-old female enrollee has requested reimbursement for gene test FoundationOne (procedure codes 81201, 81210, 81211, 81235, 81270, 81275, 81292, 81295, 81298 and 81321) on 4/6/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees metastatic breast cancer to the liver and bones.The physician reviewer found that the FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers that can help guide therapy decision making. Per the National Comprehensive Cancer Network (NCCN) guidelines, it has not been determined if molecular markers are useful in treatment determination (predictive markers) and prognosis other than for estrogen receptors (ER) and progesterone receptors (PR), and human epidermal growth factor receptor 2 (HER). FoundationOne provides genetic testing to guide therapy, and is the subject of an ongoing phase II trial. As such, it would be considered investigational/experimental for this patient. At this time, it is not likely to be more effective than available standard therapy for evaluation of this patient. All told, gene test FoundationOne (procedure codes 81201, 81210, 81211, 81235, 81270, 81275, 81292, 81295, 81298 and 81321) performed on 4/6/16 was not likely to have been more efficacious than other methods of evaluating this patient.  Therefore, for the reasons stated above, the services at issue were not likely to have been 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 42-year-old female enrollee has requested reimbursement for gene test FoundationOne (procedure codes 81201, 81210, 81211, 81235, 81270, 81275, 81292, 81295, 81298 and 81321) on 4/6/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees metastatic breast cancer to the liver and bones. The physician reviewer found that there is some evidence in the medical literature to support the efficacy of the services at issue in this clinical setting.  Von Hoff and colleagues conducted a study of 86 patients where the progression-free survival on regimen selected by molecular profiling was compared to progressive free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has very significant results for patients with stage IV tumors. Recent data on breast cancer also supports the use of FoundationOne testing. In this patients case, the results from FoundationOne profiling offers a rational selection of the next regimen.  In sum, gene test FoundationOne (procedure codes 81201, 81210, 81211, 81235, 81270, 81275, 81292, 81295, 81298 and 81321) performed on 4/6/16 was likely to have been more efficacious than other methods of evaluating this patient. Therefore, for the reasons stated above, the services at issue were likely to have been 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

The patient is a 27-year-old male who presented with complaints of difficulty concentrating. The patient was referred to the neuropsychology service on 9/6/17 by his primary care provider. The patient has requested reimbursement for neuropsychological testing provided from 9/20/17 through 10/4/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. From the clinical perspective, according to the American Academy of Clinical Neuropsychology, the decision to order neuropsychological testing for an individual patient remains a matter of clinical judgment. However, the medical records do not include objective observations such as a mental status evaluation, physical examination or validated rating scales like the Folstein Mini-Mental State Examination or Montreal Cognitive Assessment. There was no report of learning disorder, neurological disease, abrupt personality change, bizarre behavior or memory decline. It does not appear that the patient had engaged in treatment or lifestyle modification to address the inattention. The patients siblings were reportedly diagnosed with attention deficit hyperactivity disorder (ADHD). However, neuropsychological testing is not needed to establish the diagnosis of ADHD. Thus, the neuropsychological testing provided from 9/20/17 through 10/4/17 was not medically necessary for evaluation of the patients medical condition. Based on the foregoing discussion, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 43-year-old female enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found that minimally invasive SI joint fusion has not been demonstrated to result in superior health outcomes for the treatment of back pain when compared to standard available treatment options. Further, this patients medical records do not show any evidence of SI joint instability, fracture, or tumor, thus the criteria for SI joint fusion are not met. This patient has chronic back pain after previous lumbar fusion surgery. The pain is likely degenerative in cause. For these reasons, the requested SI joint fusion 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 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 Overturned

Summary Reviewer 2


A 43-year-old female enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found that according to the coverage criteria by the International Society for the Advancement of Spine Surgery (ISASS), specific criteria must be met for all patients treated with minimally invasive SI joint fusion. The criteria require documentation of significant SI joint pain, SI joint pain confirmed with at least three physical examination maneuvers that stress the SI joint, confirmation of the SI joint as a pain generator with 75% or greater acute decrease in pain upon fluoroscopically guided diagnostic intra-articular SI joint block using local anesthetic, failure to respond to at least six months of non-surgical treatment consisting of non-steroidal anti-inflammatory drugs and/or opioids and one or more of the following: rest, physical therapy, SI joint steroid injection, and failure to respond means continued pain that interferes with activities of daily living and/or results in functional disability, as well as a record that additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been ruled out. The peer-reviewed medical literature also supports SI joint fusion as there are well-constructed trials to permit scientific conclusions when these specific criteria are met. Polly and colleagues recently demonstrated that minimally invasive SI 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 SI joint dysfunction caused by degenerative sacroiliitis or SI joint disruptions. Pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment. As this patient has adequately satisfied all criteria, she is an appropriate candidate for a right SI joint fusion. Accordingly, the requested SI joint fusion is 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 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 43-year-old female enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found that this patient meets the criteria for a minimally invasive SI fusion. In the peer-reviewed medical literature, Polly and colleagues reported on a randomized controlled trial of 148 patients treated with minimally invasive SI joint fusion using triangular titanium implants or nonsurgical treatment with follow-up at one year. The authors concluded that this level one study showed that minimally invasive SI 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 SI joint disruptions. In another recent study, Whang and colleagues found that six month follow-up from this level one study showed that minimally invasive SI joint fusion using triangular titanium implants was more effective than nonsurgical management in relieving pain, improving function, and improving quality of life in patients with SI joint dysfunction due to degenerative sacroiliitis or SI joint disruptions. Based upon a review of the recent literature, the requested minimally invasive form of SI joint fusion is 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 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 Upheld

Summary Reviewer 

A 70-year-old female enrollee has requested reimbursement for inpatient treatment provided from 5/20/15 through 5/21/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the the medical necessity for inpatient treatment provided from 5/20/15 through 5/21/15 has not been established in this clinical setting. According to Mount, a variety of drugs can raise the serum potassium, primarily by interfering with the renin-angiotensin-aldosterone system (RAAS). The most common are angiotensin inhibitors such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs), aldosterone antagonists and other potassium sparing diuretics. In this case, the patient had hyperkalemia due to self-discontinuation of a potassium-wasting diuretic while continuing a RAAS medication. These are reversible causes of hyperkalemia. The patient was effectively treated in the ED. The documentation supports that the patient remained stable and tolerated treatment. The patients potassium level had normalized by 5/20/15 and there were no further indications for acute inpatient hospitalization. Therefore, the inpatient services provided from 5/20/15 through 5/21/15 were not indicated for this patient. Based on the 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 64-year-old male enrollee has requested reimbursement for inpatient stay performed on 1/13/18. 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 this patient presented after a fall from a ladder. He was diagnosed with bilateral radial nondisplaced fractures that did not require surgical treatment. He was treated conservatively with oral pain medications and splinting and discharged home the same day with plans for outpatient follow-up. The inpatient admission was not medically necessary for this patient. 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. His pain was well-controlled, and he did not have exacerbations of chronic medical problems. Therefore, the inpatient stay provided on 1/13/18 was not 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 female who has been followed for a diagnosis of polymyositis with onset in early 2017. In a letter dated 7/17/20, the provider noted that the patientas disease has been difficult to control due to a poor response to medications and poor tolerance. She is currently on prednisone and intravenous immunoglobulin. The physician reviewer found that the idiopathic inflammatory myopathies (IIM) are a heterogeneous group of acquired disorders characterized by chronic inflammation of striated muscle leading to predominantly proximal muscle weakness. The most common subsets of IIM include adult polymyositis (PM), adult and juvenile dermatomyositis (DM), myositis in overlap with cancer or another connective tissue disease and inclusion body myositis (IBM). The general clinical consensus among physicians is to use high-dose corticosteroid therapy as the first-line option in patients with myositis. However, several patients discontinue steroid treatment early because of a lack of improvement and/or adverse events. In patients with myositis resistant to conventional treatment, the anti-CD20 monoclonal antibody rituximab is a potential treatment option. 
The benefit of rituximab was demonstrated in the study by Oddis and colleagues. This study included 200 patients with polymyositis, dermatomyositis, or juvenile dermatomyositis not controlled by corticosteroids and other immunosuppressive agents. Patients were randomized to receive different regimens of rituximab (two infusions at baseline or 8 weeks later). Although the group treated with rituximab at onset did not improve significantly earlier than the group treated after a delay of 8 weeks (the primary endpoint), the majority of patients (83%) responded to rituximab treatment, and a significant steroid-sparing effect was reported. Fasano and colleagues reviewed 48 studies of refractory myositis patients treated with rituximab. They identified 458 patients with myositis treated with rituximab and found a rate of response to rituximab of 78.3%. They concluded that rituximab can play a role in the management of patients with myositis. In this case, the patient has polymyositis which has been poorly responsive to standard therapy. Based on the studies above, a majority of patients respond favorably to Rituxan and a significant steroid-sparing effect is noted. Therefore, the requested medication is medically necessary for the treatment of the patientas medical condition.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 57-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/01/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the service at issue in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Therefore, digital breast tomosynthesis performed on 9/01/16 was likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the service 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


A 57-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/01/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion and results in decrease callbacks and increase overall diagnostic accuracy and detection of small cancers compared to two-dimensional mammography alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional mammographic protocol was likely of greater benefit to the patient than had her mammogram been done with two-dimensional imaging alone.  Based upon the information set forth above, the service 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 57-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/01/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures better enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis performed on 9/01/16 was likely to have been more effective than other methods of evaluating this patient.  Based upon the information set forth above, the service 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 Upheld

Summary Reviewer 1

A 58-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 2/20/18. 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 there is a lack of support for the services at issue in this clinical setting. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. There is rarely any systemic surveillance imaging, further lymph node interrogation or recommendation for adjuvant therapy. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. The DecisionDx-Melanoma gene expression profile test is an expression assay designed to predict distant metastasis in stage I and stage II melanoma patients. DecisionDx-Melanoma assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class 1 (i.e., low risk of metastasis) or Class 2 (i.e., high risk of metastasis). However, the medical evidence has not established that DecisionDx-Melanoma testing is likely to be more effective than other standard methods of evaluating this patient. Therefore, DecisionDx-Melanoma testing performed on 2/20/18 was not likely to have been superior over 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.