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

Summary Reviewer 2

A 41-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/26/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that various (mostly retrospective) studies of prognostic gene expression profiling (GEP) testing suggest its role as an independent predictor of worse outcome, although not superior to Breslow thickness or sentinel lymph node status. It remains unclear whether this GEP profile is reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation studies are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Existing and emerging GEP platforms and other prognostic techniques should also be compared with optimized contemporary multivariable phenotypic models. This patient has a good prognosis based on pathological findings and has not yet had a wide local excision. Therefore, DecisionDx-Melanoma testing performed on 5/26/20 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 41-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/26/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that 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 this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it 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. Therefore, DecisionDx-Melanoma testing performed on 5/26/20 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 62-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 3/05/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. There is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. 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. Therefore, DecisionDx-Melanoma testing performed on 3/05/19 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 76-year-old male enrollee has requested reimbursement for the Oncotype DX Colon Cancer Assay (CPT 81525) performed on 10/25/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees stage II colon cancer. The physician reviewer found that per the National Comprehensive Cancer Network (NCC) guidelines, there is insufficient data to recommend multi gene assay panels including Oncotype DX Colon Cancer Assay for determination of need of chemotherapy. The Oncotype DX Colon Cancer Assay has not been demonstrated to predict the response to oxaloplatin based chemotherapy and thus is not indicated for this patient with stage II colon cancer. Given these findings, the Oncotype DX Colon Cancer Assay (CPT 81525) performed on 10/25/17 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

A 76-year-old male enrollee has requested reimbursement for the Oncotype DX Colon Cancer Assay (CPT 81525) performed on 10/25/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees stage II colon cancer. The physician reviewer found that the peer-reviewed medical literature has not established the utility of molecular markers in treatment determination and prognosis in patients with colon cancer. The Oncotype DX Colon Cancer Assay does not have specific U.S. Food and Drug Administration (FDA) approval for use in stage II colon cancer. Further, the assay has not been proven to predict which patients with stage II disease could benefit from adjuvant therapy. Moreover, the American Society of Clinical Oncology (ASCO) guidelines do not address use of this assay. Accordingly, the Oncotype DX Colon Cancer Assay (CPT 81525) performed on 10/25/17 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

A 76-year-old male enrollee has requested reimbursement for the Oncotype DX Colon Cancer Assay (CPT 81525) performed on 10/25/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees stage II colon cancer. The physician reviewer found that it has been demonstrated in the medical literature that adjuvant chemotherapy is beneficial to patients with stage III colon cancer. However, the usefulness of adjuvant chemotherapy in patients with stage II cancer remains controversial. Some of the features that have been associated with a higher risk of recurrence in node-negative patients include poorly differentiated cancer, lymphovascular invasion, presentation with obstruction or perforation, or a T4 tumor (Rodriguez, et al). However, this patient has none of these features. In the absence of these high risk feature, the Oncotype DX Colon Cancer Assay (CPT 81525) performed on 10/25/17 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 1

The patient is a 64-year-old female who was diagnosed with rectal cancer in 2016. The biopsy indicated that it was an invasive squamous cell carcinoma. On 12/13/16, it noted that the patient had a lower anterior resection with lymph node sampling followed by concurrent radiation and chemotherapy with cisplatin and capecitabine from March 2016 through April 2016. Imaging was concerning for progressive disease. According to the records, the tumor may have been a direct extension from a neighboring site. With regressive disease, a tumor sample was sent for mutational profiling and for immunohistochemistry analysis. The patient has requested reimbursement for the CarisMI profile testing services performed on 3/10/17. The Health Insurer denied this request as investigational for the evaluation of this patients medical condition. Several large comprehensive cancer centers have instituted targeted screening of solid tumors for mutations in oncogenes that have U.S. Food and Drug Administration approved targets. This patient was noted to have progressive disease on standard therapies and so her provider decided to sequence for mutation or screen for overexpression in EGFR, BRAF, FLT3, JAK2, KRAS, NPMT, APC, and ABL1. In a study by Von Hoff and colleagues, the progression free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has very significant results for patients with stage IV tumors.  As such, these studies offer some rationale in support of mutational testing for patients in this clinical setting. The Physicians Data Query of the National Cancer Institute (NCI) lists targeted therapy as a treatment option for stage IV or recurrent colon cancer. The NCI provides a list of examples, many of which require special analysis of the tumor specimens. Accordingly, CarisMI profile testing services performed on 3/10/17 was likely to have been more effective than the standard forms of evaluating this patients medical condition. Therefore, for the reasons stated 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 Upheld

Summary Reviewer 2

The patient is a 64-year-old female who was diagnosed with rectal cancer in 2016. This patient was diagnosed with localized (T3N0M0) squamous cell cancer of the rectum. The patients provider sent a sample tissue for molecular testing which was initiated on 2/28/17. The patient has requested reimbursement for CarisMI profile testing services performed on 3/10/17. The Health Insurer denied this request on the basis that the services at issue were investigational for the evaluation of this patients medical condition. In this case, the services at issue were not likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. This patient has localized (T3N0M0) squamous cell cancer of the rectum. Expanded genomic profiling panels are not considered standard testing to assist in managing and directing treatment. Standard therapy incudes local therapy, surgery and radiation, with or without chemotherapy. The standard of care for patients diagnosed with squamous cell cancer is targeted therapy hence the extensive genomic panel ordered including immunohistochemistry would not have been indicated in this clinical setting.  In addition, next generation panels may prove useful after failure of the standard of care, primarily to help identify new potentially actionable targets and/or for clinical trial purposes. However, obtaining expanded next generation testing at diagnosis is not reflective of the clonal evolution at relapse or disease refractoriness. In sum, the CarisMI profile testing services performed on 3/10/17 were not likely to be more effective than the standard methods of evaluating this patients medical condition. Therefore, for the reasons stated 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

The patient is a 64-year-old female who was diagnosed with rectal cancer in 2016. This patient has localized (T3N0M0) squamous cell cancer of the rectum. The patients provider sent a sample tissue for molecular testing which was initiated on 2/28/17. The patient has requested reimbursement for CarisMI profile testing services performed on 3/10/17.  The Health Insurer denied this request as investigational for the evaluation of this patients medical condition. Molecular profiling, also known as next generation sequencing (NGS) is not considered a standard of care for the treatment of recurrent or locally progressive anal carcinoma. Its use is not endorsed by the National Network Cancer guidelines. Immunotherapy is used for salvage therapy and studies show a benefit from both nivolumab and pembrolizumab. PD-L1 overexpression should not be used to select patients for treatments targeting the PD-1 pathway as studies have shown benefit even in those with no expression. NGS would not have been more beneficial for treatment decision making for this patient. As such, CarisMI profile testing services performed on 3/10/17 was not likely to have been of greater benefit than any available standard of care.  Therefore, for the reasons stated 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 

A 51-year-old female enrollee has requested reimbursement for continued inpatient stay from 7/02/19 through 7/15/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The patient had an unstable pathologic cervical spine fracture of T1. She underwent the posterior decompression and stabilization procedure on 6/20/19. She underwent the anterior portion of the procedure on 7/16/19.  The patient was hospitalized during the entire period from 6/19/19 through 7/25/19.  During her stay, and up until the secondary stabilization procedure of 7/16/19, she had an unstable fracture. It is for this reason that the patient remained in hospital. This was the safest and most expeditious way to maintain control of both the patients spine as well as her overall health. The medical evidence supports the services at issue in this clinical setting. Therefore, continued inpatient stay from 7/02/19 through 7/15/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 58-year-old male enrollee has requested reimbursement and prospective authorization and coverage for the ventilator positive airway pressure (VPAP) durable medical equipment provided from 8/2/14 forward. The Health Insurer has denied this request indicating that the device at issue was not and is not medically necessary for treatment of the enrollees severe sleep disordered breathing.  The physician reviewer found that the records indicate that this patient has severe obstructive sleep apnea. He did not respond to standard CPAP or BiPAP, and VPAP was initiated. The patient has been compliant with the therapy, and is responding well to it. VPAP is an advanced form of autotitrating BiPAP therapy and is indicated in this case to treat this patients obstructive sleep apnea. Thus, the VPAP durable medical equipment provided from 8/2/14 forward was and is medically necessary. Given these findings, the device at issue was and is 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 21-year-old female enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization level of care provided from 9/29/15 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 behavioral health condition. The physician reviewer found the episodic placement at higher levels of care is often necessary, modern psychiatric practice aims to place patients in the least restrictive treatment setting to optimize treatment gains and foster autonomous resilience. Although the patient has likely benefitted from the disputed service, the record does not support the medical necessity of partial hospitalization programming at this time. Upon presentation, the patient was at a healthy weight. Her body mass index was within normal limits. Her electrocardiogram was normal sinus rhythm. Her blood pressure was normal as was her heart rate, except upon measurement in the supine position which routinely thereafter returned mildly bradycardic in the mid-50s. The patient did have a normal glucose initially followed by hypoglycemic readings in late September. It does not appear that the blood sugar was re-tested until early November at which time it was within normal limits.  According to the psychosocial assessment, the patient was described as eloquent, intelligent, motivated with a supportive family. On 9/10/15, the patient was started on a serotonergic enhancing medication for her mood and anxiety. On 9/23/15, the patient had a normal bone scan. On 9/24/15, the patients weight was stable. She completed 100% of her meals and snacks. She reported single episodes of purging on 9/22/15 and 9/23/15.  During her therapy session that day, she named her eating disorder and expressed re-invigorated motivation to get back on track. The therapist noted that the patient was becoming more insightful regarding her eating disorder. On 9/26/15, the patient was calm, social and comfortable at meal time. She ate 100% of her meals at a steady pace with minimal supervision. On 9/27/15, the patient had a successful dinner with her parents.  On 9/28/15, the patient was active in programming and demonstrated no eating disordered behavior. The record did not describe any medical issues or psychiatric distress.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 28-year-old male enrollee has requested reimbursement for residential treatment center services from 2/1/17 through 2/2/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavior health condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. Although addiction specialty services were indicated, the clinical documentation does not demonstrate the medical necessity of treatment in a 24 hour supervised setting from 2/1/17 through 2/2/17.  Despite the patients nausea and dehydration, which necessitated a bolus of intravenous fluids and administration of an anti-emetic medication, the patient did not have a medical condition or psychiatric syndrome that warranted residential placement. The patient was working a program for his addiction and he was motivated in his treatment. The patient had safe and sober housing.  He had a supportive family.  The patient was not using drugs.  The records note that he was tolerating the medications prescribed for his detoxification and insomnia.  In sum, outpatient based treatment would have been safe and appropriate at the time. As such, the residential services from 2/1/17 through 2/2/17 were not medically necessary for the treatment of this patients medical condition. Therefore, for the reasons stated above, the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The parent of a 16-year-old female enrollee has requested reimbursement for mental health residential level of care provided from 7/17/19 through 9/17/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that 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 3. The medical records indicate that the patient was not actively suicidal, but she did have a history of speaking of suicide and some mention of thoughts without plan during treatment. Further, there is history of a previous suicide attempt in the past.  With regards to functional status, the records support a score of 2. The patient demonstrated significant improvement in function following a period of deterioration. She had good grades in school prior to admission. In terms of comorbidity, the records support a score of 1. The patient did not have active medical problems or active substance use issues. With regards to level of stress of the recovery environment, the records support a score of 2. There was no indication of an unsafe home environment. In terms of level of support of the recovery environment, the records support a score of 2. The patients family was actively involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 3. It appears that the patient had not engaged in significant treatment prior to residential treatment admission. Per the records, her only treatment was weekly therapy, which did not appear adequate for her symptoms. It would not be expected that symptoms would resolve with this minimal outpatient treatment and no psychiatric management. In terms of acceptance and engagement of the patient, the records support a score of 2. The patient was cooperative in treatment. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 17. This score correlates with intensive outpatient services. Therefore, mental health residential level of care provided from 7/17/19 through 9/17/19 was not medically necessary for the treatment of this patient.