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

Summary Reviewer 3


A 41-year-old male has requested authorization and coverage for the LINX procedure.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures.  At this time, additional studies are needed to determine the long-term safety and efficacy as compared to other treatment modalities.  Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention, which is a concern in this patients case.  The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication.  Thus, the requested LINX procedure is not likely to be more effective than other treatment options.  Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 21-year-old female enrollee has requested reimbursement for substance abuse residential services provided from 5/15/19 through 5/16/19. 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 American Society of Addiction Medicine (ASAM) criteria for level of placement can be applied to the patients presentation to help determine whether the patient met criteria for residential care. With regards to dimension 1, acute intoxication and/ or withdrawal potential, the patient met this criteria due to withdrawal symptoms. In terms of dimension 2, biomedical condition and complications, the patient met this criteria due to active medical issues. With regards to dimension 3, emotional/behavioral or cognitive conditions and complications, the patient met this criteria due to anxiety and suicidal ideation. In terms of dimension 4, readiness to change, the patient met this criteria. With regards to dimension 5, relapse, continued use, or continued problem potential, the patient met this criteria based on the records. In terms of dimension 6, recovery/living environment, the patient also met this criteria per the clinical notes. Therefore, ASAM criteria were met for residential care. Thus, substance abuse residential services provided from 5/15/19 through 5/16/19 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1
A 49-year-old female enrollee has requested reimbursement for a digital breast tomosynthesis that was performed on 3/22/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for the enrollees breast examination The physician reviewer found there is limited peer-reviewed literature that supports the use of three dimensional breast tomosynthesis (DBT) over currently available techniques. Although DBT may be a promising technique, its clinical efficacy has yet to be substantiated as superior to currently available standard medical therapies in peer-reviewed literature.  Thus, the digital breast tomosynthesis portion was not likely to be superior to available standard modalities for evaluation of this patient. Based upon the information set forth above, the service at issue was not likely to be more beneficial than any available standard therapy for evaluation of the patient. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 49-year-old female enrollee has requested reimbursement for a digital breast tomosynthesis that was performed on 3/22/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for the enrollees breast examination The physician reviewer found there is evidenced base support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis, to the usual two dimensional protocol was likely to be more effective than had her examination been performed using two dimensional imaging alone. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 49-year-old female enrollee has requested reimbursement for a digital breast tomosynthesis that was performed on 3/22/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for the enrollees breast examination 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, her breasts have been described as extremely 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. Therefore, digital breast tomosynthesis performed on 3/22/16 was likely to have been of greater benefit than other modalities for 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 1

The parent of an 11-year-old male enrollee has requested reimbursement for the FirstStepDx PLUS test provided on 7/6/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees attention deficit hyperactivity disorder (ADHD). The physician reviewer found that the clinical utility of CMA is well established, and is now considered first-line genetic tests for patients with developmental delays and autism spectrum disorders according to the American Academy of Pediatrics, the American College of Medical Genetics, the American College of Neurology and the Child Neurology Society (Schaefer, et al; Moeschler, et al; Shevell, et al; Shen, et al). In a study by Coulter and colleagues, a retrospective chart review of CMA testing was performed on patients with developmental delay, intellectual disability, autism spectrum disorders and congenital anomalies. Findings in this study demonstrated that CMA results influenced medical care in the majority of patients by precipitating medical referrals, diagnostic imaging, or specific laboratory testing, supporting the use of CMA as a clinically useful diagnostic test. It is for these reasons, that the FirstStepDx PLUS test provided on 7/6/16 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 testing 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

The parent of an 11-year-old male enrollee has requested reimbursement for the FirstStepDx PLUS test provided on 7/6/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees attention deficit hyperactivity disorder (ADHD). The physician reviewer found that Chromosomal microarray (CMA) is recommended by the American College of Medical Genetics as a first-line test for patients with autism spectrum disorders. The yield of CMA in patients with autism spectrum disorders is estimated to be around 10%. While findings on CMA may not alter treatment of the features associated with autism spectrum disorders in all patients, CMA has become the standard of care in this clinical setting. Increasing numbers of patients with autism spectrum disorders have been found to have underlying copy number variations. As such, it is possible that some copy number variations have also been associated with neuropsychological treatments or medications that have been shown to be more efficacious in this patient population. Additionally, copy number variations on CMA may inform about possible other complications and medical risks. All told, the FirstStepDx PLUS test provided on 7/6/16 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 testing 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

The parent of an 11-year-old male enrollee has requested reimbursement for the FirstStepDx PLUS test provided on 7/6/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees attention deficit hyperactivity disorder (ADHD). The physician reviewer found that array-based comparative genomic hybridization, also known as chromosomal microarray (CMA) has become standard of care to evaluate children with developmental delay, intellectual disability, autism spectrum disorders or congenital anomalies. 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 patients presentation meets the criteria established for microarray use with autism spectrum disorder and a congenital anomaly. In addition, the patients positive family history provides additional support for testing (Baris, et al; Johnson, et al). Henderson and colleagues demonstrated that approximately 12.7% of patients meeting referral criteria had a pathogenic copy number variant identified on microarray, and that half of those results influenced management. Riggs and colleagues found that 7% of microarray results impact clinical management, a rate which is similar to other genetic tests. Data have now emerged showing that actionable findings from chromosomal microarray justify its use. Thus, the FirstStepDx PLUS test provided on 7/6/16 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 testing 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 35-year-old female enrollee has requested reimbursement for NxGen MDx Universal panel and Harmony Prenatal test provided on 11/12/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for treatment of the enrollees pregnancy.] The physician reviewer found that the Harmony Prenatal cell-free DNA testing provided on 11/12/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Cell-free fetal DNA testing is an accepted approach to aneuploidy screening in high risk individuals (Devers, et al). In this case, the patient had increased risk based on her age of 35 at the expected time of delivery. However, the NxGen MDx Universal panel provided on 11/12/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Genetic carrier screening with NxGen MDx Universal panel is not recommended without a family history or ethnic background placing a patient at increased risk for the screened genetic disorders. According to Grody and colleagues, the standard of care for prenatal/preconception population carrier screening for common single-gene autosomal recessive disorders (such as cystic fibrosis and spinal muscular atrophy) and a panel of single-gene autosomal recessive conditions specifically for the Ashkenazi Jewish population. The patients records do not document a family history or ethnic background to support the NxGen MDx Universal panel. Based upon the information set forth above, a portion of 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.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 35-year-old female enrollee has requested reimbursement for NxGen MDx Universal panel and Harmony Prenatal test provided on 11/12/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for treatment of the enrollees pregnancy. The physician reviewer found that Cell-free DNA screening (cfDNA) has emerged as an important advance in screening pregnant women for common aneuploidies, specifically those seen more commonly with advanced maternal at age 35 or older at the time of delivery. While cfDNA screening is not recommended for all pregnant women in the place of traditional first and second trimester screening, most genetic societies support cfDNA testing for primary screening for higher-risk pregnant populations, including patients who of advanced maternal age at delivery. In this case, the patient had an estimated age of 35 at the time of delivery and meets the criteria for this test. In addition, national guidelines support that pregnant women should be screened for carrier status for cystic fibrosis and spinal muscular atrophy with the extended carrier screening test. In this case, the testing at issue was clinically indicated as part of the patients standard prenatal care. Accordingly, the NxGen MDx Universal panel and Harmony Prenatal test provided on 11/12/15 were 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 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 35-year-old female enrollee has requested reimbursement for NxGen MDx Universal panel and Harmony Prenatal test provided on 11/12/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for treatment of the enrollees pregnancy. The physician reviewer found that the Harmony Prenatal test provided on 11/12/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the patient was estimated to be over 35 years of age at the time of delivery. Thus, Harmony Prenatal test screening was indicated for this patient based on the support in the peer-reviewed the literature and national guidelines. However, the NxGen MDx Universal panel was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Testing utilizing the NxGen MDx Universal panel is indicated for patients with a specific family history. A review of this patients chart does not document any specific risk factors as her history of a previous pregnancy loss secondary to an incompetent cervix is not a factor indicating a specific risk of a genetic disorder. Based upon the information set forth above, a portion of the testing 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 partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The parent of 10-year-old male enrollee has requested reimbursement for biofeedback treatment services provided from 3/05/18 through 5/14/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that attention deficit/hyperactivity disorder is thought to be the most common psychiatric disorder of school-age children. Although the cause is unknown, there are many theories under investigation involving brain anatomy and chemistry. Genetics and environmental factors may also play important roles. Neurofeedback has been extensively studied in the attention deficit/hyperactivity disorder population. Previous meta-analyses have contradicted the methods and results from those that came prior, making it difficult to come to a consensus regarding the efficacy of this treatment technique. Bussalb and colleagues concluded that neurofeedback is an effective treatment for attention deficit/hyperactivity disorder, with studies showing a statistically significant improvement on assessment. More intense treatment was found to increase clinical efficacy. Micoulaud-Franchi and colleagues noted improvement in the inattention dimension of attention deficit/hyperactivity disorder symptoms. Therefore, biofeedback treatment services provided from 3/05/18 through 5/14/18 was likely to have been superior over other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

The parent of 10-year-old male enrollee has requested reimbursement for biofeedback treatment services provided from 3/05/18 through 5/14/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that biofeedback is a technique that enables an individual to learn how to change physiological activity for the purposes of improving health and performance. Neurofeedback is the type of biofeedback most often cited in research regarding attention deficit/hyperactivity disorder. There is an emerging body of evidence supporting its clinical use. Gonzalez-Castro and colleagues analyzed the efficacy of neurofeedback compared with pharmacological support and the combination of both. In this study, the participants executive control and cortical activation were assessed before and after treatment. The results indicated that the combined group obtained more benefits, and the neurofeedback group improved to a greater extent in executive control than the pharmacological support group. While this recent data has been encouraging, the meta-analysis by Cortese and colleagues noted evidence from well-controlled trials with probably blinded outcomes currently fails to support neurofeedback as an effective treatment for attention deficit/hyperactivity disorder. Goode and colleagues noted there are significant gaps in knowledge regarding the effectiveness of attention deficit/hyperactivity disorder nonpharmacologic treatments. In sum, although recent data has been encouraging, evidence for the use of biofeedback/neurofeedback is still lacking. Thus, biofeedback treatment services provided from 3/05/18 through 5/14/18 was not likely to be of greater benefit than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

The parent of 10-year-old male enrollee has requested reimbursement for biofeedback treatment services provided from 3/05/18 through 5/14/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the services at issue in this patients case. Biofeedback/neurofeedback is not generally recognized for the treatment of attention deficit/hyperactivity disorder. Holtmann and colleagues reported stringent meta-analysis of eight randomized controlled trials published in 2013 found that the effects were stronger for unblinded measures and three recent subsequently published well-controlled trials found no effects for the most blinded attention deficit/hyperactivity disorder outcome. Firmer conclusions must await upcoming evidence from larger controlled studies and future meta-analyses contrasting different forms of neurofeedback and different outcome measures. In a meta-analysis by Cortese and colleagues, the authors concluded that the evidence currently fails to support neurofeedback as an effective treatment for attention deficit/hyperactivity disorder. The authors noted future efforts should focus on implementing standard neurofeedback protocols, ensuring learning, and optimizing clinically relevant transfer. In sum, biofeedback treatment services provided from 3/05/18 through 5/14/18 was not likely to have been superior over other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


The parent of a 14-year-old male enrollee has requested authorization and coverage for surgery for scoliosis. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that the requested surgery is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature supporting anterior vertebral body tethering (VBT), which is a fusionless treatment option for management of idiopathic adolescent scoliosis. The study by Samdani and colleagues is a retrospective chart review which evaluated the clinical and radiographic outcomes of anterior VBT at one-year follow-up. The authors concluded that the results indicate that anterior VBT is a safe and potentially effective treatment option for skeletally immature patients with idiopathic scoliosis. These patients experienced an improvement of their scoliosis with minimal major complications. Given the above, surgery for scoliosis is likely to be more beneficial for treatment of thepatients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.