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

Summary Reviewer 3

The parent of a five-year-old male enrollee has requested reimbursement for the comparative genomic hybridization (CGH) FirstStep DX Plus testing performed on 10/15/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The medical literature supports CGH to be performed as the initial investigative tool for evaluating children with developmental delay (Michelson, et al). CGH is well established as the initial assessment study for any developmentally delayed child. The testing at issue was clinically indicated as it is the most effective tool available for establishing an etiology in this clinical setting. For the reasons provided, the comparative genomic hybridization (CGH) FirstStep DX Plus testing performed on 10/15/15 was likely to have been 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 24-year-old transgender female enrollee has requested reimbursement for breast augmentation performed on 6/7/17. The Health Insurer has denied this request indicating that the procedure at issue was not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found that the medical necessity for breast augmentation in transgender females with gender dysphoria is a case specific determination. This patient is well documented to have gender dysphoria. The medical literature supports breast augmentation in male to female patients as part of gender reassignment surgery. In this patients case, based on her diagnosis and history, her external anatomy should be more consistent with a female rather than a male.  Her examination detail and the photographs support that she has had insufficient breast development despite hormonal therapy. Thus, prior to the procedure, her breasts were more consistent with a male chest contour. Preoperative photographs show evidence of minimal breast development, consistent with her history. Since the condition did not resolve with hormone therapy, surgical intervention to treat this patients gender dysphoria was medically reasonable and appropriate. As such, the surgical breast augmentation performed on 6/7/17 was medically necessary for the treatment of this patients gender dysphoria. Therefore, for the reasons stated above, the procedure at issue was medically necessary. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 21-year-old male enrollee has requested reimbursement for polymerase chain reaction testing performed on 6/07/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the patient had complaints of aching in his penis and perineum.  He was initially treated on 2/18/19 with one gram of azithromycin for these symptoms. Testing for gonorrhea and chlamydia was negative. On 4/11/19, he was seen again with a history of aching in his perineum and penis and difficulty in maintaining an erection. He was given three weeks of doxycycline. His symptoms persisted, and he had a tender prostate on physical examination. He was given ciprofloxacin for three weeks. The patients symptoms improved, but then recurred. After referral to a urologist, broad spectrum screening by polymerase chain reaction testing was ordered. The medical evidence does not support the services at issue in this clinical setting. The testing was not directed at potential pathogens that cause prostatitis. Moreover, there is a lack of evidence in the medical literature that polymerase chain reaction screening is an effective or appropriate method to use in identifying the causes of prostatic symptoms. The patients complaint of being unable to sustain an erection is not related to prostatic infection and suggests other factors might be present. Therefore, polymerase chain reaction testing performed on 6/07/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 21-year-old male enrollee has requested reimbursement for polymerase chain reaction testing performed on 6/07/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient appears to have had chronic prostatitis and was evaluated and treated with several antibiotic regimens. Per the records, gonorrhea and chlamydia testing was negative.  His symptoms seem to improve, but returned after cessation of antibiotics. The urine was then sent for DNA analysis. It is standard of care to obtain bacterial, viral and fungal cultures for the diagnosis and management of prostatitis. DNA analysis is not the standard of care for this evaluation. In sum, polymerase chain reaction testing performed on 6/07/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 21-year-old male enrollee has requested reimbursement for polymerase chain reaction testing performed on 6/07/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient continued to have signs and symptoms of chronic prostatitis, including persistent pyuria, most commonly indicating infection. Standard diagnostic testing, including culture for chlamydia and gonorrhea, as well as bacterial pathogens, did not reveal the cause of the persistent prostatitis. Standard antibiotic regimens were tried and were not successful. At that point, the specimen was sent for next generation sequencing. Although next generation sequencing has not yet made it into most guidelines for diagnosis and treatment of urinary tract infections, it plays an increasing role in cases where traditional culture and standard treatment trials have failed in an individual patient. In this case, the patient had several trails of antibiotics and negative cultures for chlamydia and gonorrhea by traditional culture methods. Therefore, next generation sequencing was a reasonable next step in the diagnosis of persistent symptoms and pyuria. Thus, polymerase chain reaction testing performed on 6/07/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


An 18-year-old female enrollee has requested reimbursement for residential treatment program services provided from 7/26/14 through 5/22/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the residential treatment center services provided from 7/26/14 through 9/26/14 were medically necessary for treatment of the patients medical condition, but not thereafter. RTC level of care was initially indicated due to the patients emotional deregulations, depression, passive suicidal ideation and poor insight. However, by 9/26/14 the patient was documented to be upbeat and demonstrated a positive response to individual therapy. The patient was not a danger to herself or others. She was medically and psychiatrically stable. After the initial two months of treatment, she could have been stepped down to a lower level of care such as partial hospitalization or intensive outpatient services. Moreover, treatment closer to home would have allowed her develop her relationship with her family and to work with her therapist. As such, residential treatment center services provided from 7/26/14 through 9/26/14 were medically necessary, after which she could have been treated at lower level of care. Therefore, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The patient is a 62-year-old female with invasive urothelial carcinoma status post chemotherapy using Gem/Cisplatin followed by a radical cystectomy revealing a high grade T4NxMx yP2aypN2. The patient subsequently developed a right inguinal lymph node on 6/29/17 with pathology consistent with metastatic urothelial cancer, multiple retroperitoneal lymph nodes were subsequently documented and the patient was started on pembrolizumab. FoundationOne testing on 8/15/16 revealed multiple genomic alterations. The patient has requested reimbursement for the FoundationOne gene test provided on 8/15/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational.  In the peer-reviewed medical literature, FoundationOne testing has not been demonstrated to improve patient outcomes as compared to standard testing. According to the National Comprehensive Cancer Network (NCCN), to demonstrate clinical utility of panel genetic testing such as FoundationOne, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. The available literature consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. This evidence is insufficient to support the use of FoundationOne in lieu of standard testing. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the FoundationOne test provided on 8/15/16 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 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 2

The patient is a 62-year-old female with a history of invasive urothelial carcinoma, high grade T4NxMx (y2aN2) status post right inguinal node biopsy on 6/29/17. Pathology was consistent with metastatic urothelial cancer, high grade with plasmacytoid features. Treatment included neoadjuvant chemotherapy with four cycles of cisplatin and gemcitabine and cystectomy. FoundationOne gene testing was performed on 8/15/16. The patient has requested reimbursement for the FoundationOne gene test provided on 8/15/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational. This patient underwent molecular profiling with FoundationOne testing on 8/15/16 shortly after initial diagnosis and prior to receiving first-line therapy. As noted in the current peer-reviewed medical literature, molecular profiling is not considered the standard of care for the treatment of urothelial cancer. Moreover, in this case, the FoundationOne testing was performed when several first- and second-line therapies were available. Molecular testing to guide therapy is the ongoing subject of several active clinical trials. All told, the FoundationOne gene test provided on 8/15/16 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 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

The patient is a 62-year-old female with metastatic urothelial cancer. She presented with right hydronephrosis and an irregular bladder wall. This was bladder cancer at stage T4. She underwent transurethral resection of bladder tumor and was treated with gemcitabine and cisplatin. By June 2017, she had a right inguinal lymph node that had metastatic urothelial cancer. A staging computed tomography (CT) in July 2017 showed extensive abdominal lymphadenopathy with evidence of diffuse metastatic disease. A tumor sample was submitted to FoundationOne for mutational testing. The patient has requested reimbursement for the FoundationOne gene test provided on 8/15/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational. One standard regimen for advanced bladder cancer is methotrexate, vincristine, doxorubicin, and cisplatin (MVAC) (Sternberg, et al). Regimens with fewer drugs have been compared head-to-head with MVAC but have not performed as well in terms of survival advantage but have demonstrated reasonable response rates (Mead, et al; Hillcoat, et al). Von Hoff and colleagues reported on a study of 86 patients where the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The authors noted that the regimen selected by molecular profiling offered a 27% survival advantage. This trial has very significant results for patients with stage IV tumors. Given this support, the FoundationOne gene test performed on 8/15/16 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 41-year-old female enrollee has requested authorization and coverage for Xeljanz. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting. This patient has been diagnosed with rheumatoid arthritis. In addition to having failed methotrexate, Orencia and Actemra, the patient also failed a reasonable trial of two anti-tumor necrosis factor agents, Cimzia and Enbrel. The current literature supports the use of a drug with a different mechanism of action than anti-tumor necrosis factor agents. Per Emory and colleagues, if more than one tumor necrosis factor (TNF) inhibitor provides inadequate responses and/or similar tolerability issues, switching to a different class of agent may provide a more effective option. Gottenberg and colleagues noted that among patients with rheumatoid arthritis previously treated with anti-TNF drugs but with inadequate primary response, a non-TNF biologic agent was more effective in achieving a good or moderate disease activity response at 24 weeks than was the second anti-TNF medication. Therefore, Xeljanz is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 37-year-old female enrollee has requested authorization and coverage for lymphaticovenous anastomosis and intraoperative indocyanine green lymphatic mapping. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the proposed procedure has been studied for over a decade, and the peer-reviewed literature supports the benefit of the procedure. Scaglioni and colleagues performed a systematic review of lymphovenous anastomosis for the treatment of lymphedema. The authors noted, aAlthough the studies included in this review showed great heterogeneity, lymphovenous anastomosis surgery revealed both objective and subjective improvements in most patients.a Thomas and colleagues noted, aThe findings suggest that the real impact of living with lymphedema is much more challenging than previously identified. The findings suggest that lymphovenous anastomosis can give a future of greater choice for some of its recipients, but further research should explore longer-term benefits. Lymphovenous anastomosis could offer hope to some people with lymphedema, but a realistic expectation is essential.a There is sufficient support for the requested services in this clinical setting. Therefore, lymphaticovenous anastomosis and intraoperative indocyanine green lymphatic mapping is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 37-year-old female enrollee has requested authorization and coverage for lymphaticovenous anastomosis and intraoperative indocyanine green lymphatic mapping. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. Baltzer and colleagues stated, aPatient selection is key to the success of lymphovenous anastomosis. Patients are selected who have clinical stage 1 or 2 lymphedema using the International Society for Lymphology classification. Patients who have been compliant with nonoperative measures and do not demonstrate considerable improvement in symptoms and quality of life should be considered for surgery. Proximal lymphedema can also improve after lymphovenous anastomosis performed in the distal extremity.a Akita and colleagues stated, aVascularized supraclavicular lymph node transfer is an effective technique for the treatment of advanced stage lower extremity lymphedema. Lymphaticovenular anastomosis is also effective, but to a lesser degree than vascularized surgical lymph node transfer. However, lymphaticovenular anastomosis is less invasive and requires a shorter hospital stay.a Lymphovenous anastomosis is an established surgical treatment for lower extremity lymphedema. Therefore, lymphaticovenous anastomosis and intraoperative indocyanine green lymphatic mapping is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 37-year-old female enrollee has requested authorization and coverage for lymphaticovenous anastomosis and intraoperative indocyanine green lymphatic mapping. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that Lymphovenous anastomosis is indicated for patients with early lymphedema who have failed nonoperative management. In order for lymphovenous anastomosis to be effective, the affected extremity must have partially functioning lymphatics and minimal fibrosis. Scaglioni and colleagues conducted a meta-study of lymphovenous anastomosis surgery. The authors noted, aA total of 293 titles were identified, out of which 18 studies including 939 patients were deemed eligible. The studies included in this review describe significant variations in surgical techniques, number of anastomoses and supplementary interventions. All studies reported objective reductions in circumference measurements. Subjective symptom relief was found in 50a100% of the patients as well as a reduction in the number of cellulitis episodes in all investigated cases.a A meta-analysis by Basta and colleagues found that excess circumference and limb volume were decreased by an average of 48.8% and 56.6%, respectively. They also report a 91.2% subjective improvement in symptoms. Quality of life has also been shown to be significantly improved. While randomized control trials that are needed to clarify indications and refine techniques for optimal patient care, lymphaticovenous anastomosis in particular, appears to be a technique that is finding wider use as a valuable tool in treatment of early stage lymphedema. Therefore, lymphaticovenous anastomosis and intraoperative indocyanine green lymphatic mapping is likely to be more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a 17-year-old female enrollee has requested reimbursement for residential treatment center services provided from 2/20/15 through 11/23/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation supports the medical necessity of a portion of the services at issue.  At the time of admission, the patient had been referred from a wilderness program.  She was described as labile, and lacking in insight and coping skills despite over two months in the wilderness program.   Although she denied active suicidal or homicidal ideation, the patient was a danger to herself and others based on her emotional dysregulation and acting out behavior.  She was labile, easily triggered, and extremely unpredictable.  By 4/14/15, she was less labile, more firmly engaged and appropriate in her interactions in group, individual, and family therapies, and gaining insight into her behavior.  At that point, there was not a high likelihood of her requiring acute hospitalization were she not to be in residential treatment.  Although the patient required continued intensive treatment in a highly structured environment, she did not necessitate 24-hour supervision at residential level.  Although later into the residential stay, she demonstrated rageful outbursts, once she was at what appeared to be this plateau, it would be difficult to predict any future event and keep her at a higher level of care in anticipation of such an event which may or may not occur.  All told, residential treatment center services provided from 2/20/15 through 4/14/15 were medically necessary, but not thereafter.  Therefore, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.