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

Summary Reviewer 1


A 25-year-old female has requested authorization and coverage for intravenous ceftriaxone.  The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the requested medication in this clinical setting.  There is a lack of evidence that this patient has any infection.  The records do not describe a tick bite or the development of a rash at the site of the bite.  Her symptoms are non-specific.  There is also no evidence for either Babesia or Brucella infection. One month of ceftriaxone is accepted therapy for Borrelia infection if cardiac disease is present, neurological involvement is documented or joint involvement is found.  In this case, none of these forms of infection is present.  The notes state she is being treated for neurological infection, but there is no evidence to support this diagnosis.  The current medical evidence has not demonstrated that greater than 28 days of therapy is of benefit for patients with Lyme disease, and the records do not demonstrate that she has Lyme disease.  In sum, intravenous ceftriaxone is not likely to be superior over other treatment options.  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 25-year-old female has requested authorization and coverage for intravenous ceftriaxone.  The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found the medical evidence does not support the requested medication in this patients case.  The patients symptoms are non-specific, and the examination findings are non-focal.  The laboratory examination was negative for Borrelia infection.  The diagnosis of late stage neuroborreliosis or Lyme arthritis has not been established.  If the diagnosis of neuroborreliosis was established, the standard of care is one four-week course of intravenous ceftriaxone.  Repeat or longer term courses of antibiotic have not been shown to be efficacious. The peer-reviewed literature does not demonstrate evidence for the requested medication in this clinical setting. All told, the requested intravenous ceftriaxone is not likely to be superior over other methods of treating this patient.  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 25-year-old female has requested authorization and coverage for intravenous ceftriaxone.  The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the requested medication in this clinical setting.  She underwent 28 days treatment with intravenous ceftriaxone following oral therapy.  The most recent guidelines for the treatment of Lyme disease do not recommend prolonged or repeated therapy for the same episode of Lyme.  Per the medical evidence, central nervous system Lyme disease should be treated with a duration of 14 days, with a range of 10 to 28 days.  This patient was treated with two weeks of ceftriaxone followed by another 28 days.  The medical evidence does not support the requested medication in this case.  Thus, the requested intravenous ceftriaxone is not likely to be superior over other treatment alternatives.  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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

This patient is a six-year-old male who was diagnosed with acute flaccid myelitis in October 2018. The patientas parent has requested authorization and coverage for RT300 FES Rehabilitation Therapy System. The Health Insurer has denied this request and reported that the requested device is not medically necessary for the treatment of this patient. The physician reviewer found that the medical literature provides sufficient evidence that supports the benefit of RT 300 FES system over other standard, traditional therapy modalities alone in achieving better outcomes with strengthening, reduced spasticity and improved quality of life. The indications for the RT300 FES Rehabilitation Therapy System for this patient with acute flaccid myelitis and paraplegia are valid and supported by current medical research. These indications include prevention of muscle disuse atrophy, relaxation of muscle spasms, improving blood circulation, prevention of osteoporosis, maintaining or increasing range of motion, prevention of contractures, and cardiac and pulmonary deconditioning. The functional status, the medical history of the patient with secondary complications of the acute flaccid myelitis paraplegia, the prognosis of his injury and neurological level of involvement support the use of this modality. Therefore, RT300 FES Rehabilitation Therapy System is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 41-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 11/06/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services 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 that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  All told, breast tomosynthesis performed on 11/06/15 was 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 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 Overturned

Summary Reviewer 2


A 41-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 11/06/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.The physician reviewer found the current medical evidence supports the services at issue in this patients case.  Breast tomosynthesis has been demonstrated to be of particular benefit in women with extremely dense and heterogeneously dense tissue.  The tomographic nature of this technique often allows radiologists to separate dense underlying glandular elements from architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers.  For these reasons, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of more benefit to this patient than if she had two-dimensional imaging alone.  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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 41-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 11/06/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.The physician reviewer found breast 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 particular patient, she has breasts that have been described as being 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 enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis performed on 11/06/15 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

A 20-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 8/14/18. 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 Polymerase chain reaction testing is an appropriate test for chlamydia, gonorrhea, and trichomonas, all of which should be tested for as part of a sexually transmitted disease evaluation.  In this case, it appears the patient was tested for trichomonas, but there are no records to indicate testing for chlamydia and gonorrhea. In addition, multiple polymerase chain reaction tests were performed for various vaginal organisms, some of which do not even cause infection. The records noted that testing was performed for candida species, lactobacillus species, atopobium vaginae, megasphaera species, and Gardnerella vaginalis quantification. Polymerase chain reaction testing for these organisms is not standard of care. Standard testing for evaluation of a vaginal discharge includes assessing the symptoms, assessing the appearance of the discharge, pH testing of the vaginal fluid, examination of the discharge under the microscope, and sometimes DNA probes or cultures.  There are no records to indicate that these standard evaluations and diagnostic tests were done. In sum, polymerase chain reaction test for trichomonas was likely to have been more effective than other methods of evaluating this patient. However, the superior efficacy of the remaining tests has not been established.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 20-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 8/14/18. 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 there is sufficient support for the services at issue in this clinical setting. Polymerase chain reaction testing has been compared to traditional clinical testing for vaginitis. The literature supports the use of polymerase chain reaction testing because it has resulted in significantly higher sensitivity and negative predictive value than clinician diagnosis or in clinic testing. The test may also be superior for detecting more than one cause for vaginitis. The services at issue were appropriate in this patients case. Therefore, polymerase chain reaction testing performed on 8/14/18 was likely to have been more effective than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 20-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 8/14/18. 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 medical evidence has not demonstrated the superior efficacy of vaginitis panel testing using polymerase chain reaction technology. Although these methods have high sensitivity and specificity, including a shorter turn-around time than culture, the testing offers no proven benefit over standard culture in symptomatic women. Furthermore, there is a lack of evidence on the clinical utility and impact of polymerase chain reaction testing for vaginitis. There is a lack of studies showing that this testing leads to better patient management decisions or better health outcomes. Studies of diagnostic accuracy alone are inadequate, especially because most symptomatic women can be diagnosed with a standard work-up and/or a trial of empiric therapy. Thus, polymerase chain reaction testing performed on 8/14/18 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 30-year-old female enrollee has requested reimbursement for air ambulance transportation provided on 12/20/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who has a history of spinal muscular atrophy.  The physician reviewer found that this patient has a diagnosis of spinal muscular atrophy. She had acute respiratory failure on 11/16/17, necessitating admission to Cottage Health Hospital. During the course of her admission, the patients family made inquiries regarding transferring the patient to a facility with more expertise in treating patients with spinal muscular atrophy. By 12/19/17, the patient had been weaned from a ventilator to a tracheostomy collar. The patients family requested the patient be transferred to Rutgers University Hospital to the care of a specialist in spinal muscular atrophy where studies had been conducted to determine appropriate respiratory protocol and management strategies. However, the records do not demonstrate that this patient required emergent air ambulance transportation. The patient was hemodynamically stable. She had already been weaned to a tracheostomy collar. Although the provider at Rutgers University Hospital had conducted research with spinal muscular atrophy patients, there is a lack of evidence to support that this patient required a higher level of care at the time of her transfer. It appears the transfer was initiated at the request of the patients family. The documentation submitted does not support that this patient required emergent air ambulance transportation to receive medically necessary higher level of care at the closest hospital capable of providing such services. Thus, air ambulance transportation provided on 12/20/17 was not medically necessary for the treatment of this patient. 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


An 18-year-old male has requested reimbursement for Anser IFX testing performed on 7/09/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  This patient was losing response to the biologic treatment.  Rather than empirically dose escalate the patient, the provider recommended Anser IFX testing.  This testing determined that dose escalation would be futile.  This allowed for a rapid switch to another more beneficial agent.  In sum, Anser IFX testing provided on 7/09/15 was likely to have been superior over 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 Upheld

Summary Reviewer 2


An 18-year-old male has requested reimbursement for Anser IFX testing performed on 7/09/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the current medical evidence has not demonstrated the superior efficacy of the services at issue.  The use of Anser IFX testing to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease.  The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have clear Remicade levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, there were a lack of standard guidelines defining a therapeutic strategy at the time of testing.  A systematic review by Yarur and colleagues noted that future prospective controlled studies are needed, especially considering that anti-tumor necrosis levels are influenced by several variables that can fluctuate over time and among individuals.  In sum, Anser IFX testing performed on 7/09/15 was not 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 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


An 18-year-old male has requested reimbursement for Anser IFX testing performed on 7/09/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment.  The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  However, there are few well-controlled clinical trials to confirm that use of the Anser IFX testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results.  Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  Thus, Anser IFX testing performed on 7/09/15 was not 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 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 1

A 66-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 8/10/17.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees lung adenocarcinoma. The physician reviewer found that Adenocarcinoma of the lung should be tested for certain molecular abnormalities, including ALK, EGFR and ROS-1. Each of these has a therapeutic implication. In this case, EGFR and ALK testing were done on the initial tissue biopsy, so it is not necessary to check these on Guardant360 assay. The other use of Guardant360 assay is to look for a target at which therapy can be directed. Thus far, such use has not been shown to be clinically beneficial for the vast majority of patients. A randomized study by Le Tourneau and colleagues failed to demonstrate that choosing therapy based on molecular profiling was superior to choosing therapy based on conventional judgment. Therefore, Guardant360 testing 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 2

A 66-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 8/10/17.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees lung adenocarcinoma. The physician reviewer found that molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection beyond standard testing, such as EGFR. The National Comprehensive Cancer Network guidelines advise 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, Guardant360 testing performed on 8/10/17 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.