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

Summary Reviewer 1

A 63-year-old female enrollee has requested reimbursement for laboratory testing (collagen crosslink testing) performed on 12/03/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has been diagnosed with osteoporosis. The physician reviewer found that bone mineral density (BMD) assessment, via dual-energy x-ray absorptiometry (DEXA) is still the criterion standard for evaluation and diagnosis of osteoporosis. However, because changes in bone mass and density in response to antiresorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover may be a useful adjunct in monitoring of osteoporotic patients treated with antiresorptive agents. The medical evidence suggests that biochemical markers could be useful in making therapeutic decisions because, in general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine. There is sufficient support for the services at issue in this clinical setting. All told, laboratory testing (collagen crosslink testing) performed on 12/03/16 was likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 63-year-old female enrollee has requested reimbursement for laboratory testing (collagen crosslink testing) performed on 12/03/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has been diagnosed with osteoporosis. The physician reviewer found that markers of bone turnover, such as the collagen crosslinks, have been recognized by experts in osteoporosis as a tool to evaluate osteoporosis from diagnostic and therapeutic standpoints. There are multiple articles that show the value of this test with anabolic agents, such as Forteo, which is the medication that the patient is receiving. Antiresorptive agents decrease and anabolic agents increase the markers of bone turnover. These markers are useful to determine adherence and efficacy of therapy. This patient has received antiresorptive therapy in the past, so it is important to obtain a baseline of the markers of bone turnover. Subsequently, during therapy with Forteo, an anabolic agent, markers of bone turnover increase, and this elevation is associated to increases in bone density and therefore efficacy of therapy. Therefore, laboratory testing (collagen crosslink testing) performed on 12/03/16 was likely to have been more beneficial than any available standard test, and is an important component of monitoring 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 3

A 63-year-old female enrollee has requested reimbursement for laboratory testing (collagen crosslink testing) performed on 12/03/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has been diagnosed with osteoporosis. The physician reviewer found that there is a lack of support for the services at issue in this patients case. The value of monitoring therapy with the use of biochemical markers of bone turnover to aid in clinical decision making is controversial. This test can be variable and subject to timing and dietary intake, and there is a lack of assay standardization. In this clinical setting, dual-energy x-ray absorptiometry (DEXA) scanning would have been appropriate to monitor therapy. Thus, laboratory testing (collagen crosslink testing) performed on 12/03/16 was not likely to have been more effective than standard 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

The parent of a two-year-old female enrollee has requested reimbursement for chromosomal microarray (CMA, CPT code 81229) testing performed on 1/26/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has had a history of breath holding episodes that have increased in it severity.  The physician reviewer found that the array-based comparative genomic hybridization, also known as CMA has become standard of care in assessing children with developmental delay, intellectual disability, autism spectrum disorders or congenital anomalies.  Until recently, it was a diagnostic test that was employed when the first-line investigation of karyotype (chromosome analysis) returned normal. However, over the last 10 years it has emerged as a first line investigation.  The yield of this test is 8-17% and varies with the degree of cognitive impairment, the presence of dysmorphic features, and the presence of congenital anomalies. The medical literature indicates that this test has become an important and mainstream tool in the practice of clinical genetics.  As early as 2007, its diagnostic utility had been convincingly demonstrated, such that experts in the field were recommending its inclusion in the evaluation of any child with intellectual disability.  More recently, in a retrospective analysis by Henderson and colleagues, the clinical utility of this test was confirmed showing that 12.7% of patients meeting referral criteria had a pathogenic copy number variant identified on microarray, and that half of those results influenced management including pharmacological treatment, cancer-related screening or exclusion of screening, identifying contraindications, and referrals for further evaluation. Data have now emerged showing that actionable findings from chromosomal microarray justify its use.  In particular, Olson and colleagues found at least 5% of individuals with epilepsy had pathogenic copy number variants.  All told, the CMA testing (CPT code 81229) performed on 1/26/16 was likely to have been superior over other standard options. Based upon the information set forth 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


The parent of a two-year-old female enrollee has requested reimbursement for chromosomal microarray (CMA, CPT code 81229) testing performed on 1/26/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has had a history of breath holding episodes that have increased in it severity.   The physician reviewer found that the Health Insurer denied reimbursement for the services at issue. Per the Health Insurer, the services at issue were investigational for evaluation of this patients medical condition.
There is sufficient support in the medical literature for the efficacy of the services at issue in this patients case. The comparative genetic microarray is a deoxyribonucleic acid (DNA) test which studies a very small sampling of a patients DNA utilizing small snippets called single nuclear pleomorphisms (SNP). The test first came into clinical utilization around 2005, but subsequently has become a mainstream test for a variety of clinical conditions which are the result of genetic abnormalities. Current medical evidence supports the clinical utility of the services at issue to assist in the treatment and management of patients in this clinical setting.  Therefore, CMA testing (CPT code 81229) performed on 1/26/16 was likely to have been more effective than other forms of therapy for the evaluation of this patient.  Based upon the information set forth 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

The parent of a two-year-old female enrollee has requested reimbursement for chromosomal microarray (CMA, CPT code 81229) testing performed on 1/26/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has had a history of breath holding episodes that have increased in it severity.   The physician reviewer found that the use of chromosomal microarray testing now plays a central role in the evaluation and diagnosis of children with global developmental delay, cognitive delay, and autism spectrum disorders. In a recent consensus article by Miller and colleagues, the following statement was made: available evidence strongly supports the use of CMA in place of G-banded karyotyping as the first-tier cytogenetic diagnostic test for patients with DD/ID (developmental delay/intellectual disability), ASD, or MCA. Further, our recommendation based on current evidence is to offer CMA as the first-tier genetic test, in place of G-banded karyotype, for patients with unexplained DD/ID, ASD, or MCA.  In this patients case, she has a history of seizure like activity following breath holding spells that were increasing in frequency despite treatment with antiepileptic medications. However, the submitted records do not raise a concern of autism or global developmental delay. Moreover, there was no physical examination evidence of dysmorphic features. Based on the current literature, chromosomal microarray (CMA, CPT code 81229)  testing performed on 1/26/16 was not likely to yield a diagnosis above and beyond what has been noted clinically. Therefore, the services at issue was not likely to have been more effective than other standard options available in the evaluation of this patients medical condition.  Based upon the information set forth above, the requested 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 40-year-old male enrollee has requested reimbursement for therapeutic exercises and application modality infrared services (CPT 97026 and 97110) provided from 8/13/15 through 10/31/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees lower back pain. The physician reviewer found this patient that underwent therapeutic exercises and infrared therapy for the treatment of acute lower back pain. There is a lack of documentation demonstrating sustained, objective functional or ADL improvements obtained with therapeutic exercises and infrared therapy. In addition, there is a lack of support in the peer-reviewed literature for the services at issue in this clinical setting. Given the lack of support in the peer-reviewed literature and the documentation submitted for review, the therapeutic exercises and application modality infrared services (CPT 97026 and 97110) provided from 8/13/15 through 10/31/15 have not been established as medically necessary for treatment of the patients medical condition. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 32-year-old male enrollee has requested reimbursement for gene testing (DecisionDx-Melanoma testing) performed on 1/23/19. 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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has 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 based on the five-year risk of metastasis. Berger reported on 156 cases, but there was insufficient follow-up to determine the real value of the test. 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 assay can be used to make clinical decisions. Therefore, gene testing (DecisionDx-Melanoma testing) performed on 1/23/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 32-year-old male enrollee has requested reimbursement for gene testing (DecisionDx-Melanoma testing) performed on 1/23/19. 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 this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines indicate 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. In sum, gene testing (DecisionDx-Melanoma testing) performed on 1/23/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 32-year-old male enrollee has requested reimbursement for gene testing (DecisionDx-Melanoma testing) performed on 1/23/19. 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 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 a high depth of invasion, 0.76-1.0 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, gene testing (DecisionDx-Melanoma testing) performed on 1/23/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 60-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 8/04/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic.  The physician reviewer found that the 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 patients case, her breasts were not described as particularly dense.  However, she had a questionable area of developing new architectural distortion in one breast.  In this setting, breast tomosynthesis is valuable in separating out overlapping structures and possibly demonstrating an otherwise occult mass.  Thus, breast tomosynthesis performed on 8/04/16 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 60-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 8/04/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic.  The physician reviewer found that the current medical literature supports the service at issue in this patients case.  Per Skaane and colleague, 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, breast tomosynthesis performed on 8/04/16 was likely to have been more efficacious 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 3
A 60-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 8/04/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic.  The physician reviewer found that there is sufficient support for the service at issue in this patients case. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy compared to two-dimensional imaging alone.  In this case, there was a question of increasing architectural distortion in the left breast, prompting further investigation.  Thus, the addition of breast tomosynthesis was likely of greater benefit to the patient than had her examination 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 46-year-old male enrollee has requested authorization and coverage for an oral appliance. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees mild obstructive sleep apnea. The physician reviewer found that the submitted documentation supports the medical necessity of the requested device. The patient has been diagnosed with mild obstructive sleep apnea. Per the records, treatment with CPAP was initially recommended. The clinical notes indicate that the patient is unable to tolerate CPAP therapy. For patients who are unable to tolerate CPAP therapy, treatment with an oral appliance has been shown to improve symptoms of obstructive sleep apnea. The medical evidence supports the requested device in this clinical setting. Thus, the requested oral appliance is medically necessary for the treatment of this patient. Therefore, the requested device is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 60-year-old female enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found the requested medication is not medically necessary for treatment of the patients HCV. The documentation submitted for review fails to demonstrate evidence of the patients use of alcohol or drugs, duration of infection, presence or absence of extrahepatic manifestations. In addition, there is a lack of documentation provided about the general health of this patient to anticipate longevity. There are no hepatic imaging included as well. Given the lack of support provided within the clinical documentation submitted for review, Harvoni is not medically necessary for treatment of this patients medical condition. asons provided, the requested medication is 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 

A 60-year-old male enrollee has requested reimbursement for inpatient services provided on 2/25/19. 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 the submitted documentation supports the medical necessity of the services at issue. This patient symptomatically improved after treatment in the emergency department with morphine. He was hemodynamically stable, although bleeding from displaced rib fractures can be delayed. Per the medical evidence, three or more traumatic rib fractures meets criteria for an acute inpatient level of care. This patient had a traumatic motorcycle injury resulting in five rib fractures on the left and a hemopneumothorax. He had a history of hypertension and pre-diabetes. Due to his advanced age, medical comorbidities and the nature of the injury, acute inpatient level of care was appropriate. Therefore, inpatient services provided on 2/25/19 were medically necessary for the treatment of this patient.