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

Summary Reviewer 

A 24-year-old male enrollee has requested reimbursement and prospective authorization and coverage for substance use intensive outpatient services provided from 10/02/18 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. With regards to risk of harm, the records support a score of 2 due to recent suicidal ideation. In terms of functional status, the records support a score of 2 due to quitting a recent job and conflict with peers. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability with some mental health issues that appear under good control. In terms of level of stress of the recovery environment, the records support a score of 3 due to a stable living environment but conflict with peers there. With regards to level of support of the recovery environment, the records support a score of 3 due to mention in the records of sober living with few supports. In terms of treatment and recovery history, the records support a score of 3 due to fair recent treatment response in the intensive outpatient program. With regards to engagement and recovery status, the records support a score of 2 due to good cooperation in treatment. Thus, the patient has a composite sore of 17. This score correlates with intensive outpatient program level of care. All told, substance use intensive outpatient services provided from 10/02/18 forward were and are medically necessary for the treatment of this patient. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 54-year-old male enrollee has requested authorization and coverage for Gilotrif (afatinib dimaleate tablet 40 mg).  The Health Insurer indicates that the requested medication is investigational for the treatment of the enrollees medical condition. Therefore, the Health Insurer has denied coverage for the requested medication.
At issue is whether the requested medication is likely to be more beneficial for treatment of the enrollees condition than any available standard therapy. The physician reviewer found that the current medical evidenced supports the requested medication in this clinical setting. This patient was found to have an EGFR mutation after initial therapy with progression. Therapy at this juncture could be considered first-line therapy for the now known EGFR mutation. Afatinib has been approved by the U.S. Food and Drug Administration as first-line therapy for EGFR positive disease. Therefore, Gilotrif (afatinib dimaleate tablet 40 mg) is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2
A 54-year-old male enrollee has requested authorization and coverage for Gilotrif (afatinib dimaleate tablet 40 mg).  The Health Insurer indicates that the requested medication is investigational for the treatment of the enrollees medical condition. Therefore, the Health Insurer has denied coverage for the requested medication.
At issue is whether the requested medication is likely to be more beneficial for treatment of the enrollees condition than any available standard therapy. The physician reviewer found that the therapy of advanced non-small cell lung cancer has been revolutionized by the finding of EGFR mutations in adenocarcinomas. Even if stage IV disease is present, therapy targeted to EGFR with erlotinib results in prolonged survival when compared with standard chemotherapy regimens. The mutational landscape of non-small cell lung cancer has significantly expanded in recent years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. This patient has a rare EGFR gene rearrangement. The approach to a rare EGFR gene rearrangement is comparable to the presence of an EGFR mutation. Within the National Comprehensive Cancer Network guidelines, EGFR mutations discovered during first-line systemic therapy or those discovered prior to first-line systemic therapy should be treated with afatinib. This is a category 1 recommendation. Therefore, Gilotrif (afatinib dimaleate tablet 40 mg) is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 54-year-old male enrollee has requested authorization and coverage for Gilotrif (afatinib dimaleate tablet 40 mg).  The Health Insurer indicates that the requested medication is investigational for the treatment of the enrollees medical condition. Therefore, the Health Insurer has denied coverage for the requested medication.
At issue is whether the requested medication is likely to be more beneficial for treatment of the enrollees condition than any available standard therapy. The physician reviewer found that Afatinib is an inhibitor of EGFR. This medication is of benefit in non-small cell lung cancers, particularly adenocarcinoma, wherein there exist certain mutations of the EGFR gene. Although such mutations are rare in squamous carcinoma, they do exist, and there has been some responsiveness in squamous cell cancer with specific mutations. However, there is no real data showing reliable benefit with afatinib in patients with the very rare mutations documented in this patient. Therefore, Gilotrif (afatinib dimaleate tablet 40 mg) is not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1
A 27-year-old female enrollee has requested authorization and coverage for proton beam therapy for six weeks. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees breast cancer. The physician reviewer found that the medical literature does not support the superior efficacy of proton beam therapy over standard therapy in this clinical setting.  In the most recent version of the National Comprehensive Cancer Network guidelines, it does not address proton therapy for breast cancer, as they do for some other sites such as lung cancer.  Proton therapy can be used for select patients with unique anatomic considerations. However, the documentation provided does not demonstrate that other radiation techniques would be unacceptable and/or that proton therapy would yield a clinically meaningful advantage over conventional radiation and/or intensity modulated radiation therapy in this patient with a right-sided breast cancer. While there are studies describing its use in breast cancer, this modality is not an accepted standard of care. For this patient, proton beam therapy for six weeks is not likely to be more effective than the standard options for treatment of this patient. Therefore, for the reasons stated above, the requested services are not likely to be more beneficial for treatment of this 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 27-year-old female enrollee has requested authorization and coverage for proton beam therapy for six weeks. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees breast cancer. The physician reviewer found that there is a lack of clinical data in the medical literature to suggest that treatment with proton beam radiation offers a superior clinical benefit when compared to conventional radiation therapy techniques for breast cancer. The standard techniques to use in this clinical setting are with three-dimensional conformal or intensity modulated radiation therapy with photons instead of protons. Consensus group guidelines do not support the use of proton therapy in this setting (National Comprehensive Cancer Network Guidelines). Also, there is a lack of level I evidence to support the use of proton therapy for the treatment of breast cancer. There is a lack of clinical data to suggest that treatment with proton techniques will be able to improve the sparing of the skin, heart, and/or lungs compared to standard intensity modulated breast radiation with photon techniques. As such, proton beam therapy for six weeks is not likely to be more beneficial than other standard modalities for treatment of this patient. Therefore, for the reasons stated above, the requested services are not likely to be more beneficial for treatment of this 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 27-year-old female enrollee has requested authorization and coverage for proton beam therapy for six weeks. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees breast cancer. The physician reviewer found that the medical evidence to support the effectiveness of proton beam radiation therapy in this clinical setting is lacking.  National Comprehensive Cancer Network Guidelines do not suggest the use of proton beam for breast cancer. Although proton beam radiation therapy has been shown to be safe and effective for certain tumors that are adjacent to critical structures, there is insufficient clinical peer-review literature for supporting its use for the treatment of breast carcinoma. Also, the ASTRO emerging technology committee report does not include proton therapy for breast cancer. Instead, there are other established alternative therapies available such as conventional conformal or intensity modulated radiation therapy for treatment of breast cancer. These conventional methods have been shown to be safe and effective for the adjuvant treatment of breast cancers. All told, proton beam therapy for six weeks is not likely to be superior over the conventional methods for treatment of this patient. Therefore, for the reasons stated above, the requested services are not likely to be more beneficial for treatment of this 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 69-year-old female who presented with an abnormal mammogram. This revealed a mass on the right side measuring 0.7 cm. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this clinical setting. Current guidelines do endorse the use of intraoperative radiation therapy in the treatment of breast cancer. This patient would fall into the suitable group for the use of intraoperative radiation in patients with invasive ductal cancer. Phase 3 studies have shown equivalent outcomes in patients who undergo standard radiation therapy and intraoperative radiation therapy. The main benefit with intraoperative radiation therapy is that it can be done in a shorter course of time, and the patient does not require extra trips to a radiation oncology facility. Furthermore, treatment with intraoperative breast radiation treats only part of the breast, which may be associated with improved cosmesis. Therefore, intraoperative radiation therapy is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 70-year-old male enrollee has requested authorization and coverage for DecisionDx-Melanoma testing performed on 10/28/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that there is a lack of support in the medical literature for the services at issue in this patients case. DecisionDx-Melanoma assay claims to determine risk of recurrence for early melanoma as in this patient. However, there is a lack of data to support using adjuvant therapy in similar patients based on risk of recurrence. Adjuvant therapy is based on stage and not on the risk of recurrence as determined by this test. Moreover, the literature does not support a therapeutic advantage of this test over the standard options since this test is not designed to change or alter therapy nor alter surveillance regardless of risk. Furthermore, prospective randomized data for determination of recurrence is lacking in this test. All told, DecisionDx-Melanoma gene expression test performed on 10/28/16 was not likely to have been superior over other methods of evaluating this patients medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been 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 70-year-old male enrollee has requested authorization and coverage for DecisionDx-Melanoma testing performed on 10/28/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that a commercial gene expression profile test (DecisionDx-Melanoma) has been developed in patients with stage I and II cutaneous melanoma. However, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and 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 according to published data available. The National Comprehensive Cancer Network has not recommended its use in this clinical setting. At this time, DecisionDx-Melanoma does not appear likely to be of greater benefit than the available standard therapy. As such, DecisionDx-Melanoma gene expression test performed on 10/28/16 was not likely to have been more effective than the other methods for the evaluation of this patient. Therefore, for the reasons stated above, the services at issue were not likely to have been 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 70-year-old male enrollee has requested authorization and coverage for DecisionDx-Melanoma testing performed on 10/28/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the data on the DecisionDx test for melanoma is not 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. This was also the consensus opinion of the National Comprehensive Cancer Network (NCCN) guidelines. 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 high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision but they suggest a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon alpha. In sum, DecisionDx-Melanoma testing performed on 10/28/16 was not likely to have been more effective than the available options for the evaluation of this patients medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been 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 1
A 54-year-old female has requested reimbursement for chemotherapy treatment provided from 10/06/17 through 12/13/17. The Health Insurer has denied this request indicating that the medication regimen at issue was considered investigational for treatment of the enrollees gallbladder cancer. The physician reviewer found that FOLFIRI regimen (without bevacizumab) has an acceptable toxicity profile and a good activity, mainly in the second-line treatment. Improved overall survival and progression-free survival were found in patients who achieved partial response or stable disease. Hence, this regimen is considered standard. However, there is a lack of support for FOLFIRI with Avastin. This combination has not been tested in a randomized clinical trial showing a survival benefit. A number of phase II studies have been published showing safety only. Efficacy as measured by overall survival and progression-free survival has not been demonstrated with this combination. Therefore, the superior efficacy of the chemotherapy treatment provided from 10/06/17 through 12/13/17 has not been established. Based upon the information set forth above, the medication regimen at issue was 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 54-year-old female has requested reimbursement for chemotherapy treatment provided from 10/06/17 through 12/13/17. The Health Insurer has denied this request indicating that the medication regimen at issue was considered investigational for treatment of the enrollees gallbladder cancer. The physician reviewer found that although there is no standard second-line therapy for patients, most experts would recommend a fluorouracil based regimen after progression on gemcitabine and oxaliplatin. There are phase II trials that support the following combinations: gemcitabine/oxaliplatin, gemcitabine/capecitabine, capecitabine/cisplatin, capecitabine/oxaliplatin, 5-fluorouracil/oxaliplatin, 5-fluorouracil/cisplatin, and the single agents gemcitabine, capecitabine, and 5-fluorouracil in the unresectable or metastatic setting. There is a lack of literature to support the combination of FOLFIRI plus bevacizumab (Avastin) for second-line metastatic gallbladder cancer. In sum, chemotherapy treatment provided from 10/06/17 through 12/13/17 was not likely to have been more effective than other methods of treating this patient. Based upon the information set forth above, the medication regimen at issue was 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 54-year-old female has requested reimbursement for chemotherapy treatment provided from 10/06/17 through 12/13/17. The Health Insurer has denied this request indicating that the medication regimen at issue was considered investigational for treatment of the enrollees gallbladder cancer. The physician reviewer found that there is support for the medication regimen at issue in this clinical setting. In this case, the tumor was advanced at stage IVA. Most clinical phase II clinical trials of chemotherapy regimens in cholangiocarcinoma are small since the disease is rare. There is good evidence for the initial regimen utilized here, gemcitabine/oxaliplatin, but with progression and an Eastern Cooperative Oncology Group (ECOG) performance status of 1, a second-line regimen was appropriate. FOLFIRI is a common chemotherapy regimen effectively applied in colorectal cancer but has been extended to pancreatic and gallbladder patients. FOLFIRI/bevacizumab has been examined as second-line treatment in metastatic cholangiocarcinoma patients. The addition of bevacizumab is supported by additional independent clinical data. The FOLFIRI/bevacizumab combination is safe and effective and was medically appropriate in this patient with limited treatment options. Thus, chemotherapy treatment provided from 10/06/17 through 12/13/17 was likely to have been of greater benefit than other available treatment options. Based upon the information set forth above, the medication regimen at issue was 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 25-year-old female enrollee has requested authorization and coverage for breast reduction surgery.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that this patient has evidence of significant symptomatic macromastia.  This is noted to affect her activities of daily living with exercise.  Her stated symptoms include neck, back and shoulder pain, shoulder grooving and scarring from periodic ulcerations.  Her photographs are supportive that her clinical condition and functional deficits are likely directly related to her macromastia.  There is sufficient support for the requested services in this patients case.  Specifically, a 400 gram reduction is considered a significant reduction for a patient who is this size.  In addition, she has failed conservative management.  Breast reduction is a well-known procedure that directly addresses this functional deficit.  In this patients case, breast reduction is standard of care.  In sum, the requested breast reduction surgery is medically indicated for the treatment of this patient.  Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 24-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 in managing patients with chronic HCV denying treatment because the patient does not have an advanced stage disease is not supported by the peer-reviewed literature. According to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions.  Moreover, post hoc analysis has revealed that non-cirrhotic HCV genotype 1 patients who are treatment naive and have less than 6,000,000 IU/mL viral load can be treated with an eight week course of Harvoni, instead of 12 weeks and achieve similar cure rates. Therefore, Harvoni should be approved as medically necessary based on national guidelines. For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.