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

Summary Reviewer 1

A 68-year-old female enrollee has requested reimbursement for carbon dioxide laser surgery (Mona Lisa Touch Laser) provided on 9/12/17 and 11/3/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees vulvar atrophy. The physician reviewer found Vulvovaginal atrophy with symptomatic vaginal dryness and dyspareunia is treated with non-hormonal vaginal moisturizers and lubricants as first-line treatment. If these therapies do not provide adequate symptom relief, estrogen therapy is used. Laser treatment is available for potential treatment of vulvovaginal atrophy with urinary incontinence, as in this case. The Mona Lisa laser technology, as used in this case, delivers carbon dioxide laser energy to the vaginal wall tissue with multiple treatment sessions over a specific period of time. Current literature supports that laser therapy is promising. However, laser devices have not been approved by the U.S. Food and Administration for the treatment of vulvovaginal atrophy. Further, the American College of Obstetricians and Gynecologists has advised that although initial observational data indicate potential utility, additional data from randomized trials are needed to further assess the efficacy and safety of this procedure in treating vulvovaginal atrophy, particularly for long-term benefit. Therefore, the carbon dioxide laser surgery (Mona Lisa Touch Laser) provided on 9/12/17 and 11/3/17 were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were 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 68-year-old female enrollee has requested reimbursement for carbon dioxide laser surgery (Mona Lisa Touch Laser) provided on 9/12/17 and 11/3/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees vulvar atrophy. The physician reviewer found in this case, there is a lack documentation that standard available therapies were sufficiently tried, nor were they contraindicated, before proceeding with the Mona Lisa Touch Laser treatment. In addition, the laser therapy used is not currently U.S. Food and Drug Administration (FDA) approved for the stated indication. Thus, the carbon dioxide laser surgery (Mona Lisa Touch Laser) provided on 9/12/17 and 11/3/17 were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were 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 68-year-old female enrollee has requested reimbursement for carbon dioxide laser surgery (Mona Lisa Touch Laser) provided on 9/12/17 and 11/3/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees vulvar atrophy. The physician reviewer found the Mona Lisa Touch is a laser procedure that delivers fractional carbon dioxide laser energy to the tissue of the vaginal wall. This may allow for functional restoration of the vagina which often attenuates the symptoms related to postmenopausal vulvovaginal atrophy. However, this technology has not been approved by the U.S. Food and Drug Administration (FDA) for the specific indication for treating vulvovaginal atrophy. Preliminary observational data have shown some potential benefits but these observational trials lack long-term follow-up. In addition, no randomized trials or comparative effectiveness studies have been published. Thus, the carbon dioxide laser surgery (Mona Lisa Touch Laser) provided on 9/12/17 and 11/3/17 were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were 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 

The patient is a 71-year-old female with osteoporosis. Per the records, she has tried alendronate twice. The first time she tried alendronate was in 2010, causing neck pain and headaches. The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting. In this case, the patient has osteoporosis, and the recommendation is to treat it in order to decrease the patients risk of fracture and subsequent morbidity. Prolia (denosumab) has been approved by the U.S. Food and Drug Administration for the treatment of osteoporosis in postmenopausal women at high risk of fracture. Denosumab has been approved for first-line therapy for osteoporosis and prevention of fractures. In this case, the patient has tried an oral bisphosphonate (alendronate) twice, which in both instances was associated to systemic side effect. Therefore, J0897 (Prolia, 60 mg/ml syringe, 60 mg injected every six months for one year) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 45-year-old male enrollee has requested authorization and coverage for modafinil 200 mg. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition.  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. Based on the documentation provided for review, the patient presents with severe obstructive sleep apnea and has been appropriately treated for this condition with residual daytime sleepiness. Residual sleepiness in well-treated obstructive sleep apnea is a U.S. Food and Drug Administration (FDA) approved indication for modafinil. The medical literature demonstrates the efficacy of modafinil for this indication. Black and Hirshkowitz studied once daily modafinil or placebo in patients diagnosed with obstructive sleep apnea/hypopnea syndrome with residual excessive sleepiness during CPAP therapy. The authors concluded These results confirm previous shorter-term controlled trials, indicating modafinil is a useful adjunct therapy for improving wakefulness in patients with residual excessive sleepiness associated with obstructive sleep apnea/hypopnea syndrome who were treated with [nasal CPAP] nCPAP. For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 32-year-old female enrollee has requested reimbursement for the gene testing performed on 8/11/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees behavioral health condition. The physician reviewer found the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The medical literature suggests that continued research is still necessary to develop clear guidelines for the usage of pharmacogenetics testing. Therefore, pharmacogenetics testing is not considered the standard treatment. However, in this case, the patient has already been treated with eight different antidepressants, with at least three different pharmacodynamic strategies, and has not had a good response. Given that she has failed the standard treatments that are available, the pharmacogenetics testing was medically reasonable in this clinical setting. The genetic testing has the potential to guide the providers decisions to medications that will be better tolerated and more effective. Therefore, the gene testing performed on 8/11/16 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 Upheld

Summary Reviewer 2


A 32-year-old female enrollee has requested reimbursement for the gene testing performed on 8/11/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees behavioral health condition. The physician reviewer found that according to Kirchheiner and colleagues there is still considerable controversy on whether adjustment of dosage driven by genetic information may improve therapeutic efficacy, and/or adverse events is prevented, to an extent of any practical importance in clinical practice. The documentation provided for review does not indicate specific medication doses used, length of medication trials or combinations of medications tried and failed. The record indicates that the testing was performed due to medication failures. However, there is a lack of documentation provided as to whether the patient has been treated with psychotherapy or cognitive behavioral therapy (CBT). CBT is a first-line treatment for the generalized anxiety disorder. In sum, the documentation provided for review does not demonstrate that the patient has failed medication trials of adequate dose and duration or that the patient has tried or failed evidence based psychotherapy trials. As such, the gene testing performed on 8/11/16 has not been established as 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 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 32-year-old female enrollee has requested reimbursement for the gene testing performed on 8/11/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees behavioral health condition. The physician reviewer found that despite its promise, pharmacogenetics is not yet ready for mainstream clinical application. The American Psychiatric Association (APA) does not endorse such testing in its current clinical practice guidelines. In this case, the documentation submitted for review failed to show the patients longitudinal illness burden and extent of impairment at the time of testing, including family history, psychosocial stressors, substance use disorders and medical comorbidities. In addition, there was no mention of prior interventions used to treat panic, depression and excessive worry. Without the review of the specific type, setting and duration of psychotherapies, or, the selection, dosing and length of previous psychotropic medication trials, it cannot be inferred that the patient had exhausted standard treatments available to treat her condition. In sum, considering the relevant peer-reviewed literature and current practice standards, it is not possible to assert with any degree of confidence that the disputed gene test yielded information that significantly influenced treatment decisions, improved the patients condition, prevented a more serious episode of illness or reduced morbidity. Thus, the gene testing performed on 8/11/16 was not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was 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 26-year-old female enrollee has requested reimbursement for the L3-5 discectomy performed on 12/16/15. The Health Insurer has denied this request indicating that the surgery at issue was not medically necessary for treatment of the enrollees lumbar radiculopathy. The physician reviewer found the medical records, physical examination findings, and MRI findings do not support the medical necessity of the surgery at issue. There is no correlation between physical examination and imaging. In addition, there is no severe nerve root compression on MRI and the patient has not reportedly exhausted conservative measures. Moreover, there were no red flags for surgery or significant neurological deficit. All told, the L3-5 discectomy performed on 12/16/15 was not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the surgery at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

An 81-year-old male enrollee has requested reimbursement for Oncotype DX Prostate testing performed on 7/23/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that he National Comprehensive Cancer Network (NCCN) guidelines define the low-risk group as patients with clinical stage T1 to T2a, Grade Group 1, and serum prostate specific antigen (PSA) level less than 10 ng/mL. If the patientas life expectancy is 10 years or more, initial treatment options include: 1) active surveillance (preferred); 2) external beam radiation therapy or brachytherapy; or 3) radical prostatectomy. Molecular tumor testing can be considered for these men for prognostic information independent of NCCN risk groups. Recommendations per the NCCN guidelines support coverage post-biopsy for NCCN very-low-, low-risk, and favorable intermediate-risk prostate cancer in patients with at least 10 years life expectancy who have not received treatment for prostate cancer and are candidates for active surveillance or definitive therapy. The records indicate that this patient underwent Oncotype DX Prostate testing in 2019 as well as on 7/23/20. There is a lack of support for the services performed on 7/23/20, as Oncotype DX Prostate testing is intended for use at initial diagnosis. Therefore, Oncotype DX Prostate testing performed on 7/23/20 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

An 81-year-old male enrollee has requested reimbursement for Oncotype DX Prostate testing performed on 7/23/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features, such as the grade of tumor and PSA level. This helps guide the most appropriate therapy for patients taking into account their age and comorbidities because many patients will not require therapy (i.e. surgery or radiation) and may be followed closely instead. Most clinical variables have not been analyzed in prospective clinical trials. The important features to recognize are Gleason score and PSA, but these are imperfect. Thus, current biomarkers are inadequate for risk stratification, and better prognostic biomarkers are needed. Oncotype DX Prostate testing is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score (GPS). A validation study was presented at the American Urological Association meeting in 2013 involving 395 patients (1-3). The GPS identified patients that had very low risk disease that could be followed rather than referred for surgery. The current prognostic features are inadequate to make firm recommendations regarding active surveillance to patients. Oncotype DX Prostate testing is an appropriate test in this context. Therefore, Oncotype DX Prostate testing performed on 7/23/20 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

An 81-year-old male enrollee has requested reimbursement for Oncotype DX Prostate testing performed on 7/23/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that there currently are three major approaches to the management of localized prostate cancer. These include surgery, forms of radiation therapy, or active surveillance, with no specific anti-cancer treatment given. Treatment recommendations are made as to these options based on risk stratification, which will estimate the risk of the future development of progressive cancer. The individualas situation is evaluated, incorporating clinical factors, as well as PSA and the details of the prostate biopsy. By such methodology, the patient is placed into a risk category, ranging from very low risk, to low risk, to intermediate risk, to high risk.
A further refinement of prognostication is the use of genomic panels, such as Oncotype. This is a 17-gene panel which seems capable of predicting recurrence after treatment for prostate cancer. NCCN guidelines suggest it may be useful in decision making in the low to intermediate risk category in the initial assessment of the cancer and its treatment. In this case, Oncotype DX Prostate testing was performed after this patientas 2019 biopsy. Despite being placed into the intermediate risk category, he elected active surveillance only. Although there was minimal to no change in his clinical status in his repeat biopsy, he was considering specific treatment. In this setting, repeat Oncotype DX Prostate testing was not likely to have added to the clinical decision making, as he already had a concerning Oncotype assay in 2019. NCCN guidelines do not support the services at issue in this setting. Therefore, Oncotype DX Prostate testing performed on 7/23/20 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 

A 64-year-old male enrollee has requested reimbursement for electrical stimulation device used for cancer treatment on 1/24/19, 2/24/19 and 3/24/19. 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 in 2011, the U.S. Food and Drug Administration (FDA) approved a portable medical device that generates low-intensity alternating electric fields, also known as Optune, for the treatment of recurrent glioblastoma. Approval was based on results of a clinical trial that randomized 237 patients to tumor treating fields (TTF) or chemotherapy. Similar survival was observed in the two arms, and TTF therapy was associated with lower toxicity and improved quality of life. Consensus-based guidelines published by the National Comprehensive Cancer Network (NCCN) include alternating electric field therapy as a treatment option for patients with recurrent glioblastoma as adjuvant therapy in combination with temozolomide. Therefore, electrical stimulation device used for cancer treatment provided on 1/24/19, 2/24/19 and 3/24/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 39-year-old female enrollee has requested reimbursement for residential substance use disorders treatment provided from 11/15/19 through 11/23/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that per American Society of Addiction Medicine (ASAM) criteria, the patient meets Level 3.5 criteria, or clinically managed high-intensity residential services. With regards to dimension 1, intoxication/withdrawal potential, the patient has a history of complicated withdrawal. In terms of dimension 2, biomedical conditions and complications, the records document new onset seizures during detoxification and unsteady gait requiring walker with assistance. With regards to dimension 3, emotional, behavioral or cognitive conditions and complications, the records note comorbid depressive disorder and posttraumatic stress disorder. In terms of dimension 4, readiness to change, the patient is willing to change, but was not yet able or ready. Per the records, she qualified her motivation to engage and learn new things with, It depends on what it is. With regards to dimension 5, relapse, continued use, or continued problem potential, the patients longest sobriety prior to this was while pregnant a few years prior. In terms of dimension 6, recovery/living environment, the records document a supportive husband and mother. However, the patient reported that there was a very large wine collection at home. Prior to admission, she was able to hide her drinking from others. Given the severity of the patients illness, residential treatment was in accordance with generally accepted standards of medical practice and was clinically appropriate for the patients illness. Therefore, residential substance use disorders treatment provided from 11/15/19 through 11/23/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 23-year-old transgender male who underwent a bilateral mastectomy with nipple/areolar reconstruction on 1/16/19.  The patient has requested reimbursement for nipple/areola reconstruction performed on 1/16/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the World Professional Association for Transgender Health (WPATH) Standards of Care Version 7 states, Genital and breast/chest surgical treatments for gender dysphoria are not merely another set of elective procedures. Typical elective procedures involve only a private mutually consenting contract between a patient and a surgeon. Genital and breast/chest surgeries {are} medically necessary treatments for gender dysphoria Olson-Kennedy and colleagues also stated that chest surgery is an effective treatment of gender dysphoria in young transmasculine men. The authors noted, Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. In this case, the records documented gender dysphoria. The current medical evidence supports the services at issue in this clinical setting. Therefore, nipple/areola reconstruction performed on 1/16/19 was medically necessary for the treatment of this patient.