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

Summary Reviewer 3


A 58-year-old female enrollee has requested reimbursement for MammaPrint testing performed on 1/21/14. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for the evaluation of the enrollees breast cancer. The physician reviewer found there are several established biomarkers that are prognostically valuable in breast cancer. These include the presence of estrogen or progesterone receptors, HER2 amplification, as well as proliferative index, and histologic grade. Newer technologies such as gene expression such as the MammaPrint may also classify tumors to basal-like or luminal-type of disease. MammaPrint is U.S. Food and Drug Administration (FDA) approved and has been validated in different clinical trials. In this case, the patient was provided with adjuvant chemotherapy based on her high risk MammaPrint profile. Based on available medical evidence and medical literature, MammaPrint was likely to be more beneficial for evaluation of the patients medical condition than other modalities. 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 1


A 33-year-old female enrollee has requested reimbursement for homocysteine testing, Factor V Leiden genetic testing and methylenetetrahydrofolate reductase (MTHFR) performed on 8/7/15. The Health Insurer has denied this request indicating that the services at were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that The American College of Obstetricians and Gynecologists (ACOG) practice bulletin for inherited thrombophilias in pregnancy indicate that testing for inherited thrombophilias in women who have experienced recurrent fetal loss or placental abruption is not recommended because it is unclear if anticoagulation therapy reduces recurrence. Although there may be an association in these cases, there is insufficient clinical evidence that antepartum prophylaxis with unfractionated heparin or low molecular weight heparin (LMWH) prevents recurrence in these patients. In addition, there is insufficient evidence of an association and, therefore, insufficient evidence to either screen for or treat women with inherited thrombophilias and obstetric histories that include complications such as fetal growth restriction or preeclampsia. Moreover, there is a lack of medical literature supporting an association between the Factor V Leiden mutation and heritable thrombophilias and either pregnancy loss or obstetric complications characterized by placental insufficiency. Therefore, homocysteine testing, Factor V Leiden genetic testing and MTHFR performed on 8/7/15 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, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


A 33-year-old female enrollee has requested reimbursement for homocysteine testing, Factor V Leiden genetic testing and methylenetetrahydrofolate reductase (MTHFR) performed on 8/7/15. The Health Insurer has denied this request indicating that the services at were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that according to the medical records the patient has undergone one pregnancy loss. The American Society for Reproductive Medicine, in its Practice Committee Opinion, defines recurrent pregnancy loss as the occurrence of two or more miscarriages. Therefore the patient does not meet the standard of care definition of recurrent pregnancy loss. The American Society for Reproductive Medicine, in its practice committee opinion states Screening for inherited thrombophilias (specifically, Factor V Leiden and the prothrombin gene mutations, protein C, protein S, and antithrombin deficiencies) may be clinically justified when a patient has a personal history of venous thromboembolism in the setting of a non-recurrent risk factor (such as surgery) or a first-degree relative with a known or suspected high-risk thrombophilia. Although an association between hereditary thrombophilias and fetal loss has been suggested, prospective cohort studies have failed to confirm this. Routine testing of women with recurrent pregnancy loss for inherited thrombophilias is not currently recommended. There is no evidence that the patient has a personal or family history of a thrombophilia. Therefore there is a lack of support for the Factor V Leiden testing or any other tests for inherited thrombophilias. In addition, there is a lack of support in the peer-reviewed literature that a significant association of MTHFR and recurrent miscarriage exists. Therefore, MTHFR testing is not within the standard of care and was not likely to be more beneficial for evaluation of the enrollees 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 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 33-year-old female enrollee has requested reimbursement for homocysteine testing, Factor V Leiden genetic testing and methylenetetrahydrofolate reductase (MTHFR) performed on 8/7/15. The Health Insurer has denied this request indicating that the services at were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that The American College of Obstetricians and Gynecologists (ACOG) Bulletin states Testing for inherited thrombophilias in women who have experienced recurrent fetal loss or placental abruption is not recommended because it is unclear if anticoagulation therapy reduces recurrence.  There is insufficient evidence to either screen for or treat women with inherited thrombophilias and obstetric histories that include complications such as fetal growth restriction or preeclampsia. Because of the lack of association between either heterozygosity or homozygosity for the MTHFR C677T polymorphism and any negative pregnancy outcomes, including any increased risk for venous thromboembolism, screening with either MTHFR mutation analyses or fasting homocysteine levels is not recommended.  Moreover, thus, there was no medical justification for Factor V Leiden genetic testing and MTHFR for diagnosis and treatment of the patients medical condition.  The testing at issue 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, 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

The patient is a 59-year-old male with a history of obstructive sleep apnea (OSA). A home sleep study on 9/29/16 revealed an obstructive apnea index of 1.5 and a hypopnea index of 1.5 with a total apnea/hypopnea index (AHI) score of 2.9, and a supine AHI score of 0.0. A dental device did not alleviate the patients sleep apnea or snoring. A second home sleep study on 4/10/17 demonstrated a rise in both an obstructive apnea index of 2.9 and a hypopnea index of 10.2 with a total AHI score of 13.1. The results revealed a supine AHI of 24.6. The patient was provided with an oral appliance. The patient has requested reimbursement for an oral appliance provided on 12/6/16. The Health Insurer has denied this request indicating that the device at issue was not medically necessary. Consistent with the recommendations from the American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM), the oral appliance provided to this patient with OSA was medically necessary. The patients polysomnogram on 4/12/17 revealed findings consistent with moderate-to-severe OSA syndrome. Moreover, the results revealed a supine AHI of 24.6. As the patient was found to have moderate-to-severe supine and positional OSA syndrome, the oral appliance provided on 12/6/16 was medically necessary for treatment of this patients medical condition.  Based on the foregoing discussion, the device at issue was 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 48-year-old female enrollee has requested authorization and coverage for Stelara (ustekinumab injection) 45 mg/0.5 mL. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriasis and psoriatic arthritis. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient is requesting coverage for Stelara for treatment of psoriasis and psoriatic arthritis. She has tried and failed therapy with topical steroids, tar topicals, methotrexate, ultraviolet B (UVB) light therapy, Enbrel for 13 years, and Humira for 10 years. The Health Insurer has denied reimbursement for the requested medication because the patient has not yet tried and failed therapy with Cosentyx. In this patients case, there are no documented contraindications to the use of Cosentyx which is approved for the treatment of psoriasis and psoriatic arthritis. Given that the preferred formulary medication is effective for the condition to be treated and there are no contraindications to its use, the requested medication is not medically indicated as there are efficacious alternatives available. Thus, Stelara (ustekinumab injection) 45 mg/0.5 mL is not medically necessary for the treatment of this patient. Therefore, the requested medication is 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

The parent of a 14-year-old female enrollee has requested reimbursement for subtalar arthroereisis provided on 12/11/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral moderate-to-severe pes planus. The physician reviewer found that based on the current medical literature, it was not likely to be more beneficial for this patient to have undergone subtalar arthroereisis for treatment of bilateral flexible flatfoot than treatment with standard available options. There are as many as eight different implants that are utilized to correct valgus deformity that are inserted into the sinus tarsi. The use of sinus tarsi implants or subtalar arthrodesis as an alternative to Evans procedure is not well supported with a high incidence of failure of the implants to maintain correction, recurrence of pain and the need to remove the implants and convert to a more durable solution. In spite of the reported short-term positive benefit, the lack of durability in the prosthesis is reported in a number of studies with high rates of need for revision. The support in the literature for arthroereisis is in the form of case series studies, and the level of the support in the literature is weak. Consistent with these findings, the subtalar arthroereisis provided on 12/11/14 was not likely to have provided this patient with an improved health outcome beyond that expected with standard interventions. Based upon the information set forth above, I have determined 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

The parent of a 14-year-old female enrollee has requested reimbursement for subtalar arthroereisis provided on 12/11/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral moderate-to-severe pes planus. The physician reviewer found that review of the current peer-reviewed medical literature does not provide adequate support for the safety and effectiveness of subtalar arthroereisis for the treatment of bilateral flatfoot. Moreover, there is a lack of indication for this procedure in this patients records. As this procedure has not been proven in the medical literature as safe and effective for the treatment of this patients medical condition, the subtalar arthroereisis performed on 12/11/14 was not likely to have been more beneficial for treatment of this patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined 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


The parent of a 14-year-old female enrollee has requested reimbursement for subtalar arthroereisis provided on 12/11/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral moderate-to-severe pes planus. The physician reviewer found that in this case, the patient presented with chronic foot and leg pain due to collapsed arches that was unresolved with conservative care. The procedure has been performed by different methods in various patient populations with reports of positive outcomes in well selected patients. Schon noted the procedure had promise, while Needleman reported 78% clinical improvement, despite high complication rates. Thus, the procedure is reserved for patients who have exhausted conservative treatments. Since this patients records demonstrate that she failed all reasonable conservative therapies prior to surgical intervention, the subtalar arthroereisis performed on 12/11/14 was likely to be more beneficial than standard available modalities. Based upon the information set forth above, I have determined the services at issue were likely to be more beneficial for treatment 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 a 15-year-old male enrollee has requested reimbursement for quantification of therapeutic drug, not elsewhere specified and immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified, performed on 12/10/19. 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 therapeutic drug level monitoring has become an essential procedure in the management of inflammatory bowel disease. Measuring the drug level and the presence of antibodies can help the treating provider differentiate between primary treatment failures versus insufficient dosing. It can also allow dosing titration and adjustments. The clinical practice guidelines adopted by the American College of Gastroenterology (ACG) support the use of therapeutic drug monitoring in the management of patients with inflammatory bowel disease. There is sufficient scientific evidence supporting the benefit of biologics drug level measurement. Per Singh and Dubinsky, aTherapeutic drug monitoring allows for optimized, individualized dosing and improved care for inflammatory bowel disease patients of all ages.a Raimundo Fernandes and colleagues published a prospective study showing that proactive therapeutic drug level monitoring is associated with fewer surgeries and higher rates of mucosal healing than conventional non-therapeutic drug level monitoring-based management. Therefore, quantification of therapeutic drug, not elsewhere specified and immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified, performed on 12/10/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

The parent of a 15-year-old male enrollee has requested reimbursement for quantification of therapeutic drug, not elsewhere specified and immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified, performed on 12/10/19. 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 therapeutic infliximab drug levels and antibodies are now considered as standard of care for management of patients on Remicade. Sufficient drug levels and negative antibody levels are important to maintain long-term efficacy of the drug. Modification of drug dose based on symptoms and/or levels and antibodies may help sustain continued remission. In this patientas case, he was symptomatic the day prior to the infusion. There was evidence of poor bone health, suggesting possible active disease. The medical evidence supports the services at issue in this clinical setting. All told, quantification of therapeutic drug, not elsewhere specified and immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified, performed on 12/10/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

The parent of a 15-year-old male enrollee has requested reimbursement for quantification of therapeutic drug, not elsewhere specified and immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified, performed on 12/10/19. 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 this patient demonstrated loss of response with breakthrough symptoms prior to his scheduled medication doses. Measurement of drug and antibody levels has now been incorporated into professional guidelines, which include recommendations for both proactive and reactive therapeutic drug monitoring. Expert consensus guidelines state that it is appropriate to order drug and antibody concentration testing for all anti-tumor necrosis factor medications, including infliximab, in patients with a confirmed secondary loss of response. Guidelines specifically focusing on the pediatric age range reflect the same conclusion. The studies by Afif and colleagues and Yanai and Hanauer indicate that measurement of infliximab levels and anti-infliximab (anti-chimeric) antibodies produces actionable data. Change of dose or drug based on these results improves response to treatment, as measured by clinical response. In clinical practice, infliximab levels and antibodies allow the provider to adjust or change biologic therapy with some objective determinants. Thus, quantification of therapeutic drug, not elsewhere specified and immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified, performed on 12/10/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 50-year-old female enrollee has requested reimbursement for the lumbar injections provided on 5/28/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees back pain, right lower extremity pain with and concomitant neurological deficits.  The physician reviewer found that in the documentation available for review, this patient meets the medical necessity criteria for the lumbar injections provided on 5/28/15. Specifically, the patient presented with radicular pain associated with symptoms of nerve root irritation and low back pain due to disc extrusions and/or contained herniations. Further, the patients pain had been unresponsive to conservative treatment, including pharmacotherapy and exercise. The literature supports the use of epidural steroid injections in this clinical setting. Therefore, the lumbar injections provided on 5/28/15 were medically necessary for treatment of this patients medical condition. Accordingly, the services at issue were 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 59-year-old female enrollee has requested reimbursement for high dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, for dates of service 2/07/19, 2/09/18, 2/12/19, 2/14/19, 2/19/18, 2/21/18, 2/26/18, 2/28/18 and 3/05/18. 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. The records document squamous cell carcinoma of the skin. Per the most current American Brachytherapy Society Consensus Statement: At this time, there are growing data with respect to electronic brachytherapy and non-melanomatous skin cancer; however, there is a lack of comparative data to traditional treatments, limited data with long-term follow up, and a need for younger patients in studies before generalizing recommendations. Although data can be extrapolated from orthovoltage experiences with non-melanomatous skin cancer, in light of the large numbers of patients diagnosed with non-melanomatous skin cancer, prospective studies with larger numbers of patients undergoing electronic brachytherapy should be performed. National Comprehensive Cancer Network guidelines support these recommendations. Therefore, the superior efficacy of high dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, for dates of service 2/07/18, 2/09/18, 2/12/18, 2/14/18, 2/19/18, 2/21/18, 2/26/18, 2/28/18 and 3/05/18 has not been established.