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

Summary Reviewer 


The parent of a 15-year-old male enrollee has requested reimbursement for residential mental health treatment services provided from 5/9/15 through 8/7/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, and parent-child relational problem.  

 The physician reviewer found that the documentation provided for review does not support the medical necessity of residential mental health treatment services provided from 5/9/15 through 8/7/15. There is no evidence that treatment in a less restrictive setting would have been ineffective to manage the patient, since this had not been given an adequate trial. Similarly, there is a lack of objective evidence that continuation with a lesser intensity of care could not have provided improvement or prevention of deterioration. The patients level of symptomatology did not justify residential services. No suicidal ideations or homicidal ideations had been documented, but in one incident, which was assessed as an attempt to manipulate the staff. The patient was able to contract for safety and no additional intervention occurred. Further, continued residential services, especially at the highly intensive levels that were used, may have led to service dependency, which would be an adverse outcome. Therefore, this patient would have been more appropriately managed at a less restrictive, less intrusive intensity of services, such as outpatient care. For these reasons, the residential mental health treatment services provided from 5/9/15 through 8/7/15 were not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, 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 Overturned

Summary Reviewer 


An 18-year-old male enrollee has requested reimbursement for residential treatment from 7/01/15 through 7/31/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  The current medical evidence supports residential treatment in this clinical setting.  Per the documentation from his treatment providers, including the psychologist who evaluated him during this time, the patient was likely to have relapsed into his previous behaviors if discharged to a lower level of care.  The records describe the patient as superficial and able to present a false front to his treatment team.  Thus, he was not internalizing the changes needed to avoid a relapse.  All told, residential treatment from 7/01/15 through 7/31/15 was medically indicated for the treatment of this patient.  Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 63-year-old male with a history of extensive spine surgery, including previous L3-4 laminectomies and foraminotomies as well as an instrumented lumbar fusion at L4-5. The patient has requested authorization and coverage for right L3-L4 foraminotomies.  The physician reviewer found that lumbar foraminotomies have been an accepted surgical treatment strategy for lateral recess/foraminal stenosis for decades. This procedure is well-established for its safety and efficacy. Hu and colleagues recently performed a large retrospective cohort study on patients who underwent primary or repeat foraminotomies to compare their effectiveness. Five hundred and seventy-nine procedures were eligible for evaluation. Using validated outcome measures, the authors observed that primary and repeat foraminotomies have similar successful outcomes. This patientas provider evaluated the patient and ruled out other sources of the patientas pain. He notes dermatomal pain and sensory changes with meaningful weakness that correlates to the patientas progressive imaging changes with at least moderate foraminal stenosis noted on his most recent MRI scan. The patient attended several physical therapy sessions as noted in the records.  The documentation notes that he stopped this as it made his symptoms worse. The evidence supporting the role of physical therapy in the care of lumbar radiculopathy is lacking and of low quality despite the fact that it is one of the most prescribed treatments. In a literature review on the topic of conservative therapies for lumbar radiculopathy, Alentado and colleagues noted that there is not strong evidence to support any particular duration of this treatment. They recommend on the basis of the literature, anything from four to eight weeks. On the basis of extensive review of the records and documentation provided, the requested services are medically necessary. The patient had concordant historical and physical examination findings with the reported imaging studies. He was unable to tolerate physical therapy after attempting it. He had neurological weakness that was documented on examination. Therefore, right L3-L4 foraminotomies are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 42-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/29/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees melanoma. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either class 1 or 2, with class 2 melanomas having a significantly higher rate of recurrence than class 1. Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients undergoing sentinel node biopsy. Berger and colleagues reported on 156 cases, but there was insufficient follow-up to determine the real value of the assay. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear if the DecisionDx-Melanoma testing assay results can be used to make clinical decision, above and beyond the pathologic details. Therefore, DecisionDx-Melanoma testing performed on 8/29/18 was not likely to have been more effective than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 42-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/29/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees melanoma. The physician reviewer found that this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. This test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy. In sum, DecisionDx-Melanoma testing performed on 8/29/18 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 42-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/29/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees melanoma. The physician reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76 to 1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on 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. Thus, DecisionDx-Melanoma testing performed on 8/29/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 63-year-old female enrollee has requested reimbursement for intravitreal Eylea injections provided on 7/26/18. 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 Choroidal neovascularization (CNV) is a common cause of vision loss in patients with pathologic myopia. It is thought to arise from thinning of the retina and choroid from axial elongation, leading to ischemia and expression of vascular endothelial growth factor (VEGF). Since the arrival of anti-VEGF agents, the standard of care for treatment of CNV has shifted from laser to these medications. The most commonly used anti-VEGF agents in the eye are bevacizumab, ranibizumab, and aflibercept. Both aflibercept and ranibizumab have been studied and shown to be effective in the treatment of myopic CNVM. The current medical evidence supports the services at issue in this clinical setting. Therefore, Eylea injections provided on 7/26/18 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 38-year-old female has requested reimbursement for fecal calprotectin testing performed on 11/22/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative pan-colitis. The physician reviewer found that Calprotectin is a zinc and calcium binding protein that is derived mostly from neutrophils and monocytes. It can be detected in tissue samples, body fluids, and stools, making it a potentially valuable marker of neutrophil activity. Fecal calprotectin levels are increased in intestinal inflammation and may be useful for distinguishing inflammatory from noninflammatory causes of chronic diarrhea. An additional potential role of fecal calprotectin is in the monitoring of patients with colitis to predict whether they are going to have a disease flare and to distinguish in symptomatic patients whether the symptoms are due to inflammation or to functional disease. In this patients case, she had a recent colonoscopy showing endoscopic healing, and she had no complaints relative to her colitis. There is a lack of support for the services at issue in this setting. Thus, fecal calprotectin testing performed on 11/22/17 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 2

A 38-year-old female has requested reimbursement for fecal calprotectin testing performed on 11/22/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative pan-colitis. The physician reviewer found that persistent disease activity is associated with a poor prognosis in inflammatory bowel disease. Therefore, monitoring of patients with intent to suppress subclinical inflammation has emerged as a reasonable community-standard treatment goal. As endoscopic monitoring is invasive and resource intensive, identification of valid markers of disease activity has been a priority. Calprotectin, when measured in feces, is commonly used in clinical practice to differentiate between non-organic and inflammatory intestinal disorders, especially to identify inflammatory bowel disease. Fecal calprotectin may also be useful to monitor patients with inflammatory bowel disease under treatment and to predict the risk of recurrence of active disease prior to clinical relapse. However, in this patients case, all available data at the time of the disputed service supported disease quiescence off conventional medications, as well as an absence of signs and symptoms attributable to inflammatory bowel disease. The medical evidence does not support the services at issue in this clinical setting. Therefore, fecal calprotectin testing performed on 11/22/17 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

A 38-year-old female has requested reimbursement for fecal calprotectin testing performed on 11/22/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative pan-colitis. The physician reviewer found that the use of fecal calprotectin is supported for management of patients with ulcerative colitis to prevent invasive interventions such as colonoscopy. A randomized, prospective, controlled trial by Lasson and colleagues evaluating patients with ulcerative colitis showed lower relapse rate than control when using calprotectin to direct management with medications. Another prospective study by Costa and colleagues showed that unlike in Crohns disease, fecal calprotectin was sensitive and specific for prediction of relapse in ulcerative colitis, making it a useful tool for non-invasive monitoring. In this patients case, the test allowed for assessment of ulcerative colitis disease activity without colonoscopy. For these reasons, fecal calprotectin testing performed on 11/22/17 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 Upheld

Summary Reviewer 1

A 47-year-old female enrollee has requested reimbursement and prospective authorization and coverage for pertuzumab injections from 8/18/15 forward. The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees medical condition. The physician reviewer found pertuzumab is a monoclonal antibody that targets HER2 positive breast cancer cells, similar to, but not exactly in the same way as trastuzumab.  In metastatic breast cancer, when used in combination with chemotherapy and trastuzumab, pertuzumab yields superior progression-free survival compared to treatment with Taxotere-Herceptin without pertuzumab.  Combining pertuzumab with Herceptin and chemotherapy also appears to be superior to the combination without pertuzumab in the neoadjuvant situation.  However, there is a lack of data to support the use of combining pertuzumab with trastuzumab in the adjuvant setting.  Therefore, the superior efficacy of pertuzumab injections from 8/18/15 forward has not been established.  Based upon the information set forth above, the services at issue were not and 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 Upheld

Summary Reviewer 2

A 47-year-old female enrollee has requested reimbursement and prospective authorization and coverage for pertuzumab injections from 8/18/15 forward. The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees medical condition. The physician reviewer found pertuzumab has been shown to increase pathologic complete responses in patients with HER2 positive breast cancer.  Pertuzumab is recommended for neoadjuvant therapy for four to six cycles, and if not given in the neoadjuvant setting, may be given for four to six cycles as adjuvant therapy.  However, there is a lack of support for adjuvant therapy with pertuzumab in this clinical setting.  Therefore, pertuzumab injections from 8/18/15 forward were not and are not likely to be of greater benefit than other treatment options.  Based upon the information set forth above, the services at issue were not and 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 Upheld

Summary Reviewer 3


A 47-year-old female enrollee has requested reimbursement and prospective authorization and coverage for pertuzumab injections from 8/18/15 forward. The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the records fail to demonstrate the superior efficacy of the services at issue.  In this clinical setting, chemotherapy and one year of trastuzumab is the standard of care. Pertuzumab is a humanized monoclonal antibody that binds to the extracellular portion of the HER2 protein. The U.S. Food and Drug Administration (FDA) has approved its use in metastatic breast cancer and in neoadjuvant treatment of HER2-positive locally advanced, inflammatory, or early stage breast cancer.  However, it is not part of regimens given postoperatively.  Furthermore, the FDA approval was based on pathologic complete response rates and not on survival criteria.  Per the current medical evidence, pertuzumab injections from 8/18/15 forward were not and are not likely to be of greater benefit than other alternatives.  Based upon the information set forth above, the services at issue were not and 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 Upheld

Summary Reviewer 1

A 61-year-old male enrollee has requested authorization and coverage for intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery (including anterior cervical procedures). The Health Insurer indicates that the requested services are investigational for the treatment of the enrolleeas medical condition. Therefore, the Health Insurer has denied coverage for the requested services. At issue is whether the requested services are likely to be more beneficial for treatment of the enrollee's condition than any available standard therapy. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This is a spinal deformity operation plus placement of pedicle screws. Intraoperative monitoring is needed to monitor the L5 nerve root during reduction and correction of spondylolisthesis to minimize foot drop and permanent palsy. Additionally, the requested services will allow the provider to monitor for any breach of pedicle screws. Given how long the surgery will take in prone position, the requested services can also allow the provider to monitor the upper extremity to make sure the patient does not end up with a brachial plexus and/or ulnar nerve palsy. Therefore, intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery (including anterior cervical procedures) is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


A 61-year-old male enrollee has requested authorization and coverage for intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery (including anterior cervical procedures). The Health Insurer indicates that the requested services are investigational for the treatment of the enrolleeas medical condition. Therefore, the Health Insurer has denied coverage for the requested services. At issue is whether the requested services are likely to be more beneficial for treatment of the enrollee's condition than any available standard therapy. The physician reviewer found that Charalampidis and colleagues performed a review summarizing relevant studies regarding the utilization of intraoperative neurophysiological monitoring technique in spine surgery. The authors concluded, aAlthough there are no prospective studies validating the efficacy of IONM, there is a growing body of evidence supporting its use during spinal surgery. However, the lack of validated protocols to manage intraoperative alerts highlights a critical knowledge gap. Future investigation should focus on developing treatment methodology, validating practice protocols, and synthesizing clinical guidelines.a This 61-year-old male was being treated for strain of the lumbar region; sacral back pain; lumbar spondylosis; lumbar radiculopathy; pars defect of lumbar spine; chronic low back pain with bilateral sciatica, unspecified back pain laterally; and spondylolisthesis of the lumbar region. The treatment plan included a single level posterior lumbar fusion at L5-S1. Intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery was requested. However, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support this request as an exception. Therefore, intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery (including anterior cervical procedures) is not likely to be more beneficial than any available standard therapy.