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

Summary Reviewer 2

A 62-year-old female enrollee has requested reimbursement for genetic testing performed on 7/31/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation for the evaluation of the enrollees medical condition. The physician reviewer found that the DecisionDx-Melanoma test is a clinically validated prognostic tool for patients with stage 1A disease, who are not recommended for sentinel node biopsy. Traditional clinical pathologic assessment for determination of prognosis based on tumor size, and histopathologic features as described in this patients biopsy report, underreport a significant percentage of stage 1 and 2 patients who subsequently present with recurrent disease and metastases with incurable melanoma. The DecisionDx-Melanoma test has been used as a standard method for prognosis assessment, based on multiple publications detailing the test utility in melanoma patients. The DecisionDx-Melanoma test is an independent predictor of risk. In sum, testing (DecisionDx-Melanoma Gene Assay) performed on 7/31/18 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 62-year-old female enrollee has requested reimbursement for genetic testing performed on 7/31/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines states that 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, either as a standard of care or as part of clinical trials. Thus, testing (DecisionDx-Melanoma Gene Assay) performed on 7/31/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 16-year-old male with short stature whose height ((shoe)?) measurement fell to less than the 3rd percentile at age 12 years. His weight tracked above the 5th percentile. He was evaluated in June 2015 and his peak growth hormone response to arginine and clonidine was 13 ng/mL. Insulin-like growth factor-1 (IGF-1) level was 232 ng/mL and insulin-like growth factor-binding protein 3 (IGFBP-3) was 2.6 mg/L. His thyroid function tests, serum chemistry panel, and hemoglobin were normal.  His bone age in January 2016 was 13 year 6 months at 14 years 8 months. In June 2016, he stood at 151.4 cm (height standard deviation score of -2.3), and his growth velocity was 5.0 cm per year. He was started on Nutropin in October 2016 for treatment of idiopathic short stature. In January 2017, his height was 156.7 cm (height standard deviation score of -2.01) and his weight was 50.3 kg (weight standard deviation score of -1.06). His height velocity was 9.1 cm per year. Pubic hair was between Tanner stages 3 to 4, and testicular volume was 15 cc. The patients parent has requested authorization and coverage for Nutropin AQ NuSpin 20 mg/2 mL pen injector to optimize height potential for the patient. The Health Plan has denied this request and reported that the requested medication is not medically necessary for treatment of this patient.  This denial is the subject of this appeal and determination. The patient is being treated for idiopathic short stature, and as of January 2017 appear to be in the midst of his pubertal growth spurt. Prior to initiation of growth hormone (GH), the patients height was 2.3 standard deviation score below the mean for his age and gender. His growth velocity was slow for age, and his bone age was mildly delayed. According to  the Pediatric Endocrinology Society guidelines, a trial of growth hormone therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations (SD) below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity less than the 25th percentile for bone age; (3) bone age more than 2 SD below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient meets the above criteria. Accordingly, Nutropin AQ NuSpin 20 mg/2 mL pen injector is medically necessary for treatment of this patient. Therefore, for the reasons state above, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 42-year-old female who is requesting reimbursement for fetal chromosomal analysis via cell-free DNA. The records document advanced maternal age and history of prior miscarriages. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Noninvasive prenatal screening by cell-free DNA is increasingly becoming accepted as an appropriate method for first trimester aneuploidy screening. Noninvasive prenatal screening is a sensitive screen for aneuploidy, is more sensitive than sequential screening, but does not require the invasive procedure of chorionic villus sampling or amniocentesis. This is the case for both younger women and for women of advanced maternal age. This test is less invasive, with less risk to the pregnancy. Therefore, fetal chromosomal microdeletions genomic sequence analysis (81422) performed on 7/09/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 35-year-old male enrollee has requested reimbursement for the osteogenesis stimulator provided on 11/30/16. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees right ankle pain. The physician reviewer found that as noted in the medical literature, an accessory navicular is the most common extra ossicle of the foot. In cases of failed nonsurgical treatment, excision of the ossicle has been demonstrated to be effective (Jegal, et al; Rietveld and Diemer). Similarly, Marcus and Kopp found that when conservative measures fail to relieve the symptoms of a painful accessory navicular, simple excision of the accessory navicular and anatomic repair of the posterior tibialis tendon is a successful intervention. In addition, there is a lack of scientific evidence supporting the efficacy of ultrasound stimulation for treatment of foot and ankle pain in this clinical setting. All told, the osteogenesis stimulatory provided on 11/30/16 was not medically necessary for treatment of this patients foot pain. Based on the foregoing discussion, the device at issue was 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 


An 18-year-old female enrollee has requested reimbursement and prospective authorization and coverage for 52 hours per month of applied behavioral analysis (ABA) therapy provided from 10/1/15 forward.  The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees autism spectrum disorder.The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. ABA is the standard of care for treating children with autism and the medical literature supports the treatment of autistic children with ABA therapy. Although ABA therapy is the mainstay of successful treatment of autism, its successful prolonged improvement of behavior is limited to approximately 50 percent of the patient population (Vismara and Rogers). Moreover, there is a lack of medical literature showing the effectiveness of ABA therapy applied to autistic adults. In this case, the patient has adequate language, but also has difficulty in establishing social contacts and interactions. Social skills group has been suggested to improve social competence in patients aged 6 to 21 (Reichow, et al). Therefore, based upon the medical literature cited above and the documentation submitted for review, the services at issue were not and are not medically necessary. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 65-year-old male with a medical history significant for episodes of diffuse paralysis during which he appears to be conscious and conversant but unable to move freely due to profound weakness. The patient has requested reimbursement for genetic testing performed on 3/25/20. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that periodic paralysis is a group of inherited diseases that present as episodic muscle weakness and paralysis. Hyperkalemic Periodic Paralysis (HYPP, HyperKPP) is a rare condition that begins in childhood and can continue until middle adulthood or may even last into late adulthood. It presents as muscle weakness, ranging from mild weakness to paralysis. During these episodes, it is common to have higher than normal blood levels of potassium. The condition is caused by a mutation in the SCN4A gene that codes for voltage-gated sodium channel Na1.4. Several diagnostic modalities exist in assisting diagnosis, which includes genetic testing. Given the extreme phenotype of the patient in this case, coupled with the known molecular basis for periodic paralysis, genetic testing was medically necessary in order to provide adequate surveillance, enroll in studies and quantify recurrence risk. Therefore, genetic testing performed on 3/25/20 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 62-year-old female with a medical history including alcoholism, depression and anxiety who presented to the emergency department with an altered mental status after reportedly overdosing on medications. She was brought in by EMS with reports of taking Valium, Codeine and propranolol. At the time of presentation, her blood pressure and respiratory rate were stable. The physician reviewer found that at the time of admission, the patient was hemodynamically stable, afebrile with normal oxygen saturations on room air. She was diagnosed with an intentional overdose at the time of admission although psychiatry determined that she did not require a hold due to denial of intention to harm herself. She did not have any significant cardiac arrhythmias or electrolyte disturbances. She was stable for discharge within two days of admission. The inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patientas 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. Therefore, acute inpatient services provided from 8/24/20 through 8/26/20 were not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 51-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) performed on 3/18/19. 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 per the medical evidence, PCR testing is appropriate and medically indicated when done to test for chlamydia, gonorrhea, and trichomonas. In this case, the patient did have gonorrhea and chlamydia PCR, and this was covered by the Health Insurer. However, multiple additional PCR
tests were done for various other vaginal organisms, some of which do not even cause infection. PCR testing for these organisms is not standard of care. Therefore, PCR testing performed on 3/18/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 51-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) performed on 3/18/19. 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 PCR testing has been compared to traditional clinical testing for vaginitis. The literature supports the use of PCR testing due to significantly higher sensitivity and negative predictive value than clinician diagnosis or in clinic testing. PCR testing has been shown to be superior for detecting more than one cause for vaginitis. PCR testing is commonly used test in clinical practice. In this case, the postoperative period is especially difficult to make an accurate diagnosis of vaginal complaints. Missing an infection could lead to a serious complication, Thus, PCR testing performed on 3/18/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 51-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) performed on 3/18/19. 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 patients with vaginitis can be evaluated and treated with an examination, microscopy and/or cultures, depending on the patients symptoms and findings. This patient reported itching and discharge. The services performed in this patients case were clinically appropriate. Per the American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin number 215, Although microscopy with Amsel criteria and Gram staining with Nugent scoring remain the preferred methods and the most cost-effective way to diagnosis bacterial vaginosis, some newer commercially available diagnostic tests show promise for use in the clinical setting and may be considered when microscopy is unavailable. Per the medical evidence, this single-swab multiplex test may be a promising alternative to microscopy. Thus, PCR testing performed on 3/18/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 48-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 9/15/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees breast examination. The physician reviewer found tomosynthesis was approved by the Food and Drug Administration (FDA) in 2011 for clinical use and by the Centers for Medicare & Medicaid Services (CMS) for reimbursement in 2014. The American College of Radiology (ACR) recommended the technique be removed from the investigational category in 2014 due to the advantages this technique brings to radiologists. The tomographic nature of tomosynthesis enables radiologists to get a clearer picture of breast tissue as well as the nature of calcifications as present in this case. This added clarity has resulted in a decrease in false negatives and false positives. Furthermore, the use of tomosynthesis has decreased callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual 2D imaging protocol of mammography was likely of greater benefit to this patient than had she had 2D 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 2


A 48-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 9/15/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees breast examination. The physician reviewer found this patient is a 48-year-old female who has requested reimbursement for bilateral diagnostic mammogram with tomosynthesis on 9/15/15 for a 6-month calcification follow up. The report shows calcifications were unchanged from previous studies, suggesting it is probably benign, BIRADS 3. A 2013 study by Skanne and colleagues found the use of mammography plus tomosynthesis in a screening environment resulted in significantly higher cancer detection rate and enabled radiologists to detect more invasive cancers. Recent studies also show that integrated 2D and 3D mammography reduced false positive recalls (Ciatto, et al). The current literature is sufficient to support the use of breast tomosynthesis over conventional mammogram based upon improved cancer detection rates.  In this patient, the use of tomosynthesis was likely to be more beneficial for the evaluation of her medical condition than standard imaging modalities. For the reasons stated 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 48-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 9/15/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees breast examination. The physician reviewer found in recent years, several studies support the use of breast tomosynthesis as a more accurate study than routine screening mammography. Medical literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  As noted in a paper by Helvie and colleagues, this technology has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies. In this particular patient, as discussed by Kopans and colleagues, tomosynthesis is valuable in the evaluation and optimizing visualization of suspicious breast calcifications. Thus, the submitted documentation supports the service at issue in this clinical setting as tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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 1

A 57-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 12/17/15 and 1/12/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk for breast cancer.  The physician reviewer found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis studies performed on 12/17/15 and 1/12/16 were likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.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 57-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 12/17/15 and 1/12/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk for breast cancer.  The physician reviewer found that tomosynthesis was approved for clinical use by the U.S. Food and Drug Administration (FDA) in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography the American College of Radiology (ACR) supports the utility of tomosynthesis, especially in patients with extremely or heterogeneously dense tissue such as the patient under this review. This technique often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers. Thus, on the screening exam of 12/17/15, the addition of tomosynthesis to the usual two dimensional views was likely of more benefit to the patient than had the exam been done with two dimensional technique alone. However, the follow-up left diagnostic mammogram on 1/12/16 was for the purpose of characterization of the detected left breast calcifications. These calcifications required magnification spot views in 90 degree orthogonal planes and not a repeat tomosynthesis. It is unlikely that such a repeat tomosynthesis view added anything in addition to the information available on the magnification views. Accordingly, the breast tomosynthesis provided on 12/17/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy while the study performed on and 1/12/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, a portion of 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 partially overturned.