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

Summary Reviewer 1


A 68-year-old male enrollee has requested reimbursement for proton beam radiation therapy. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found that Proton beam radiation therapy was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this clinical setting, other treatment approaches such as intensity-modulated radiation therapy (IMRT) are also highly effective and well tolerated. To date, there is a lack of compelling data to suggest that proton therapy is clinically superior or more beneficial than IMRT. The National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer state that there is no clear evidence supporting a benefit or decrement to proton therapy over IMRT for either treatment efficacy or long-term toxicity. Conventionally fractionated prostate proton therapy can be considered a reasonable alternative to x-ray based regimens. In addition, a systemic review by Lodge and colleagues concluded that patients treated with proton therapy fare comparably to patients treated with photon radiation (i.e. IMRT). Another study, compared prostate IMRT with proton therapy; they concluded that there was no difference in toxicity in a comprehensive cohort of Medicare beneficiaries with prostate cancer at 12 months post-treatment (Yu et al). Therefore, the proton beam therapy was not likely to be more beneficial treatment than standard medical therapy in this clinical setting. 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 male enrollee has requested reimbursement for proton beam radiation therapy. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found that the services at issue were not likely to be more effective for this patient than other available options. Protons have been used to treat prostate cancer for last several years. There is some support in the literature for the safety and efficacy of proton beam radiation therapy for prostate cancer. However, there is a lack of randomized trial suggesting superior clinical outcome of proton beam for prostate cancer over intensity-modulated radiation therapy (IMRT). For the reasons provided, the services at issue have not been established as likely to be more beneficial than standard medical 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 male enrollee has requested reimbursement for proton beam radiation therapy. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found that based on the information submitted, there is a lack of sufficient rationale for the use of proton therapy in the treatment of prostate cancer. Proton therapy is not considered more beneficial than standard conventional radiation therapy in the treatment of prostate cancer. The patients episodic diarrhea in not a sufficient rationale for the use of proton therapy as it is unknown whether treatment with protons or photons would affect this condition.  Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Sheets and colleagues evaluated the comparative effectiveness of intensity-modulated radiation therapy (IMRT), proton therapy, and conformal radiation therapy for prostate cancer. In the comparison between IMRT and proton therapy, IMRT patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities between IMRT and proton therapy. According to the position statement by The American Society of Radiation Oncology (ASTRO) At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. Given the lack of support by national guidelines and peer-reviewed literature, the proton beam radiation therapy was not likely to be more beneficial for treatment than standard photon 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 Upheld

Summary Reviewer 


An 18-year-old male enrollee has requested reimbursement and prospective authorization and coverage for mental health residential services provided from 11/23/14 through discharge and 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 condition. The physician reviewer found the mental health residential services provided from 11/23/14 through discharge and forward were not and are not medically necessary for treatment of the patients medical condition. The patient does not meet the medical necessity criteria for residential level of care.  He is at low risk of self-harm. He was noted only once to have suicidal thoughts, and even then did not have a plan or intent.  His medical problems were stabilized, and he was continued on the same two psychotropic medications at the same dosage throughout his stay. He had moderate interference with addiction recovery, and moderate impairment in social functioning. Based on all of these factors and carefully considering American Society of Addiction Medicine (ASAM) placement criteria, residential level of care was not medically necessary in this clinical setting. The patient could have been safely and effectively managed at a lower level of care. Thus, the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 39-year-old male with a history of remote anterior cervical discectomy at C5-6 followed by adjacent segment disease and revision anterior cervical discectomy and fusion. The patient has requested authorization and coverage for spinal surgery. The Health Insurer denied the request indicating that the requested services are not medically necessary. The physician reviewer found that the patient has recurrent neck pain associated with radicular pain and evidence of left C7 radiculopathy. The MRI findings corroborate the clinical findings. He has failed conservative treatments. As such, he is a candidate for surgery. The provideras recommendation with regard to the surgical procedure is appropriate and is supported by the medical literature. No adjacent segment disease occurs below C7. As such, a total disc replacement is not necessary. The selected procedure is supported by the clinical and MRI findings and is likely to be beneficial based upon a review of the literature. The requested services are medically indicated for management of the adjacent segment disease and associated C7 radiculopathy of the patient. Therefore, spinal surgery is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a 13-year-old female enrollee has requested reimbursement for residential treatment center services provided from 1/12/15 through 2/8/16. 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 that the RTC services from 1/12/15 through 2/8/16 were medically necessary for treatment of the patients behavioral health conditions. During the treatment period in dispute, the patient worked through significant anxiety and behavioral dyscontrol through therapy, groups, dialectical behavior therapy (DBT) and medications. Based upon admission criteria by the American Academy of Child and Adolescent Psychiatry Level of Care Utilization System the patient scored a 26, indicating a need for 24-hour monitored care. In addition, the services provided were consistent and beneficial for treatment of the patients medical condition. For the reasons provided, the RTC level of care services provided from 1/12/15 through 2/8/16 were medically necessary for treatment of the patients medical condition. Therefore, 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 Overturned

Summary Reviewer 1

The patient is a 58-year-old male who has been diagnosed with prostate cancer. On 4/27/17, pathology report noted prostatic carcinoma, with highest Gleason score 3+3=6. Per the records, three cores were positive. The patient has requested reimbursement for Oncotype DX Prostate Assay performed on 9/29/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  There is a lack of support for the services at issue in this clinical setting. This test has not been validated with prospective randomized clinical trials to change outcomes and impact survival and or quality of life. The medical evidence does not support the use of this molecular test to determine the appropriateness of observation or active surveillance. Therefore, Oncotype DX Prostate Assay performed on 9/29/17 was not likely to be more efficacious than other methods of evaluating this patient. 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 Overturned

Summary Reviewer 2

The patient is a 58-year-old male with prostate cancer. On 4/27/17, prostate biopsies were performed for a prostate-specific antigen (PSA) level of 5.1. Pathology report noted prostatic carcinoma, with highest Gleason score 3+3=6. Three cores were positive. The patient has requested reimbursement for Oncotype DX Prostate Assay performed on 9/29/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. National Comprehensive Cancer Network (NCCN) guidelines note that men who are status post biopsy with low or favorable intermediate-risk disease may consider the use of Oncotype DX Prostate Assay. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of NCCN risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy, and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays. It is considered a standard of care in guiding treatment decision making. In sum, Oncotype DX Prostate Assay performed on 9/29/17 was likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

The patient is a 58-year-old male with prostate cancer. He presented with an elevated prostate-specific antigen (PSA) level of 5. He had core biopsies performed where 3 of 14 cores were positive for prostate adenocarcinoma, Gleason score 3+3=6. The patient has requested reimbursement for Oncotype DX Prostate Assay performed on 9/29/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  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 and may be followed closely instead. 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 Assay is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score (GPS). The GPS identifies 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. Thus, the Oncotype DX Prostate Assay is medically appropriate in this context. All told, Oncotype DX Prostate Assay performed on 9/29/17 was likely to be superior over other available methods of evaluating this patient. 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 


The parent of a three-year-old male enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program provided from 10/31/15 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 autism spectrum disorder with severe behavioral disturbance. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. Swiezy and colleagues state Ultimately, training specific to autism spectrum disorders and related evidence-based practices is proposed as necessary for all care providers having influence on programming related to this special population. It is also posited that the most effective avenue for training is through models incorporating more intensive and interactive training processes such as hands-on learning activities with opportunities for coaching, modeling, practice and feedback. Effective collaboration across systems (including home, medical, educational, and community settings) is emphasized to facilitate consistency in implementation of strategies for ultimate program success. In this case, the patient has tried a lower level of care which was not effective as documented by multiple providers. As of 10/30/15 the patient has still not met his targets/goals and termination of treatment at this stage would be detrimental to patients short-term as well long-term prognosis. The patient is three years old and the medical literature shows that the best outcomes are associated with early intensive intervention. Based on the support in the peer-reviewed literature and the severity of the patients behaviors, partial hospitalization program provided from 10/31/15 forward was and is medically necessary for treatment of the patients medical condition. 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 17-year-old male enrollee has requested reimbursement for acute psychiatric inpatient treatment provided from 5/23/19 through 5/26/19. 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 the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 4 due to his recent pattern of explosive behaviors. With regards to functional status, the records support a score of 5 due to serious deterioration of interpersonal interactions due to psychotic symptoms. In terms of comorbidity, the records support a score of 4 due to significant psychiatric symptoms that impair functioning in the absence of stressors. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable home environment. In terms of level of support of the recovery environment, the records support a score of 2. The patient is able to return to home, but may attend residential treatment due to symptoms. With regards to resiliency and treatment history, the records support a score of 5. The patient has not demonstrated significant remission of symptoms in the recent past despite treatment with numerous medications and electroconvulsive therapy. In terms of acceptance and engagement of the patient, the records support a score of 5. The patient showed almost no insight into his behaviors due to his level of impairment. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents appeared to work well with clinicians. Thus, the patient has a composite score of 29. This score correlates with secure 24-hour services with psychiatric management. An example of this is a hospital or secure residential treatment center. Per the records, the inpatient setting was the least restrictive environment for the patient due to continued acute symptom presentation. Therefore, acute psychiatric inpatient treatment from 5/23/19 through 5/26/19 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 47-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/06/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 47-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/06/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found there is sufficient support for the service at issue in this clinical setting.  According to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  In sum, the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  Therefore, digital breast tomosynthesis performed on 7/06/16 was likely to have been of greater benefit than other modalities for evaluating this patient.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 47-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/06/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were described as dense.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis performed on 7/06/16 was likely to have been more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.