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

Summary Reviewer 1

A 58-year-old female enrollee has requested reimbursement for the DecisionDX uveal melanoma (UM) multigene assay performed on 4/10/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees intraocular choroidal melanoma of the left eye. The physician reviewer found that DecisionDx assay is a study of 15-31 genes in an individuals melanoma cells. It has been used to classify the individuals melanoma as having either a high or low risk of metastasis. It is controversial in cutaneous melanoma as to whether it has additional value when added to the usual pathologic prognostic factors. However, there are medical studies that show the effectiveness of this assay in the analysis of prognosis for uveal melanoma (Onken, et al (2010); Onken et al (2012)). This assay is also within the guidelines of the American Joint Cancer Commission. Specifically, a class 1 category carries with it a less than 20% chance for metastasis, whereas class 2 has a greater than 70% risk of metastasis. This assay has become a standard in many ocular cancer centers and is no longer considered investigational. Its clinical value lies in determining the need for intense surveillance, and possibly to assist in the decision as to adjuvant therapy. Overall, the DecisionDX uveal melanoma multigene assay performed on 4/10/15 was likely to have been more effective than available standard modality for the evaluation of this patient. Based upon the information set forth above, the services 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 58-year-old female enrollee has requested reimbursement for the DecisionDX uveal melanoma (UM) multigene assay performed on 4/10/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees intraocular choroidal melanoma of the left eye. The physician reviewer found that there is a lack of evidence-based medical studies that support the superiority of DecisionDX assay over standard testing options for the evaluation of uveal melanoma in this clinical setting. While there are some studies that show genomic testing can lead to more frequent evaluations for metastasis, there is still is no approved adjuvant therapy for the treatment of uveal melanoma. Moreover, it has not been shown to predict response to adjuvant therapy. In summary, the DecisionDX uveal melanoma multigene assay performed on 4/10/15 was not likely to have led to greater benefit for the evaluation of this patient than other standard treatment options. Based upon the information set forth above, the service 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 Overturned

Summary Reviewer 3
A 58-year-old female enrollee has requested reimbursement for the DecisionDX uveal melanoma (UM) multigene assay performed on 4/10/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees intraocular choroidal melanoma of the left eye. The physician reviewer found that the service at issue was likely to be more effective than other methods of evaluating this patient. This patient has a rare disease, ocular melanoma.  However, knowledge of the propensity for metastasis directly affects surveillance of patients by computed tomography scan. Along these lines, there are clinical studies that support the use of gene expression classifier DecisionDX uveal melanoma. This assay defines two classes of ocular melanoma. Class 1 is associated with a low risk of metastasis and class 2 has a 50% risk at two years and 72% risk at five years. Currently, there is no other standard prognostic indicator that could serve as an alternative. Thus, the current medical evidence favors the use of this test in the post-operative surveillance of patients with ocular melanoma. As such, the DecisionDX uveal melanoma multigene assay performed on 4/10/15 was likely to be superior over other available 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.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

An 18-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health residential treatment provided from 2/20/20 through 3/05/20. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. In this case, CALOCUS, rather than the adult Level of Care Utilization System (LOCUS) was used, despite the patient being age 18, due to her developmental level, dependence on her family, and family involvement in her care. In addition, the residential treatment center she attended was a treatment center designed for adolescents. With regard to risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to two prior serious suicide attempts, and a recent pattern of excessive substance use. In terms of functional impairment, the records support a score of 4. The patient had serious functional impairment due to conflict with her family and refusal to leave the house prior to admission to the residential treatment center. With regard to comorbidity, the records support a score of 4. The patient had uncontrolled substance use. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment due to expectations for performance at home or school that create discomfort. With regard to environmental support, the records support a score of 2. The patient had a supportive environment due to her parents active participation in treatment. In terms of resiliency and response to treatment, the records support a score of 4. The patient had poor resiliency and/or response to treatment. With regard to treatment acceptance and engagement, the records support a score of 2. The patient actively participated in treatment and was motivated for change. Thus, the patient has a composite score of 22. Due to her risk of harm, the patient qualified for medically monitored residence-based services. The combination of depression, anxiety, past suicidality, family conflict, and substance use, as well as lack of response to prior outpatient treatment, placed the patient at high risk. Therefore, mental health residential treatment provided from 2/20/20 through 3/05/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

An 18-year-old male enrollee has requested reimbursement for mental health partial hospitalization provided from 1/23/18 through 1/31/18 and 2/07/18 through 2/20/18 and intensive outpatient program services provided from 2/21/18 through 3/20/18. 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 in sum, intensive outpatient program services provided from 2/21/18 through 3/20/18 were medically necessary for the treatment of this patient. The submitted documentation fails to demonstrate the medical necessity of mental health partial hospitalization provided from 1/23/18 through 1/31/18 and 2/07/18 through 2/20/18.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 61-year-old male who underwent a colonoscopy for the indication of colorectal cancer screening on 3/22/21, with monitored anesthesia care. The patient has requested reimbursement for monitored anesthesia care provided on 3/22/21. The physician reviewer found according to the ASA guidelines for anesthesia care during endoscopic procedures, monitored anesthesia care is warranted in prolonged or painful procedures, such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that monitored anesthesia care is more likely necessary in patients with a failed history of moderate sedation for the procedure or psychological impediments to cooperation. The provided records do not support any of these criteria, or other criteria in the literature, such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, age greater than 70, pregnancy, increased aspiration risk, ASA class III or higher, or morbid obesity. According to the most recent guidelines from the American Society for Gastrointestinal Endoscopy, during endoscopic procedures (unlike surgery) consciousness during the procedure is acceptable and is the goal during most procedures (which are performed with amoderate sedationa), and monitored anesthesia care is recommended for prolonged procedures requiring deep sedation, previously anticipated intolerance to standard sedatives, ASA class IV or V, or risk for airway obstruction due to anatomic variant. For these reasons, the submitted records do not support the medical necessity of monitored anesthesia care over conscious sedation in this case. Therefore, monitored anesthesia care provided on 3/22/21 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1
A 61-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/19/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee who presented for a breast examination.  The physician reviewer found that there is evidence based support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two-dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two-dimensional protocol was likely to have been more effective than had her examination been performed using two-dimensional imaging alone. Based upon the information set forth above, the service at issue was likely to have been 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 61-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/19/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee who presented for a breast examination.  The physician reviewer found that the medical literature supports breast tomosynthesis in this clinical setting.  Per 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 state that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, the literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis performed on 7/19/16 was likely to have been superior to other methods of evaluating this patient. Based upon the information set forth above, the service at issue was likely to have been 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 61-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/19/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee who presented for a breast examination.  The physician reviewer found that the 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 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.  However, in this patients case, there were no problems to be resolved.  The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications.  In this clinical setting, a routine mammogram would have been sufficient.  Digital breast tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality. Therefore, breast tomosynthesis performed on 7/19/16 was not 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 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 46-year-old female enrollee has requested reimbursement for injection of platelet-rich plasma performed on 12/21/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient presented in December 2018 with chronic bilateral heel pain. She was diagnosed with bilateral plantar fasciitis. She had reportedly failed conservative treatment, including steroid injections, orthotics, stretching, rest, ice, elevation, therapy, activity modification, and shoe modifications. On 12/21/18, she underwent bilateral platelet-rich plasma injections to the plantar fascia medial and central bands. There is a lack of large volume, long-term, peer-reviewed outcome studies to support this treatment in this patients case. Therefore, injection of platelet-rich plasma performed on 12/21/18 was not likely to have been more effective than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 46-year-old female enrollee has requested reimbursement for injection of platelet-rich plasma performed on 12/21/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the records document a history of chronic right ankle pain and bilateral heel pain. Surgery was primarily performed due to the enlarging soft tissue mass over her right lateral ankle. She reported symptoms which were characteristic of chronic plantar fasciitis. The medical evidence does not support platelet-rich plasma injections of the ankle and foot in this setting. Moraes and colleagues performed a review of 1,088 patients from 19 clinical trials for multiple conditions. The authors noted that a lack of standardization and varying preparation techniques were areas of concern. The authors concluded that there was insufficient evidence to support platelet-rich therapies for musculoskeletal soft tissue injuries. In this case, the patient was being treated for chronic bilateral plantar fasciitis as well as a right ankle soft tissue mass. Platelet-rich plasma injections were performed to treat chronic bilateral plantar fasciitis which had been refractory to conservative management. The available literature regarding tendinopathies and arthropathies of the foot and ankle do not indicate platelet-rich plasma injections are more beneficial for the treatment of foot and ankle conditions than standard conservative management. In sum, injection of platelet-rich plasma performed on 12/21/18 was not likely to have been of greater benefit than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 46-year-old female enrollee has requested reimbursement for injection of platelet-rich plasma performed on 12/21/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient received platelet-rich plasma injections into the bands of plantar fascia of both heels to enhance healing and relieve chronic pain. Gonnade and colleagues compared injections of platelet-rich plasma with phonophoresis and kinesiotaping for chronic plantar fasciitis. The study concluded that therapeutic quality autologous platelet-rich plasma injection has regenerative effect with long and better efficacy in pain management of chronic recalcitrant plantar fasciitis than phonophoresis and kinesiotaping. The study by Shetty and colleagues compared platelet-rich plasma injection with corticosteroid injections. The conclusion was that both platelet-rich plasma injections and corticosteroids are safe and effective treatments for chronic recalcitrant plantar fasciitis. Both options for chronic plantar fasciitis showed superior results to placebo treatment. However, platelet-rich plasma injections showed longer-term results and less need for reinjection or surgery, which made platelet-rich plasma injections superior to corticosteroid injections. Thus, injection of platelet-rich plasma performed on 12/21/18 was likely to have been of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 20-year-old female enrollee has requested reimbursement for residential treatment provided from 6/21/17 through 7/26/17. 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 that the submitted documentation fails to demonstrate the medical necessity of the services at issue. On 6/21/17, the patient did not have any suicidal ideation. She attended and participated in her groups and therapy sessions. She continued to have symptoms of distractibility and irritability. Per the records, the patient was compliant with her medications. She was cooperative with the staff and did not have any aggressive behavior. The patient interacted with her peers in a positive manner. The records do not demonstrate that the patient was a danger to herself or others during the dates of service in dispute. Based on the submitted documentation, the patient could have been treated in a less restrictive environment. Therefore, residential treatment provided from 6/21/17 through 7/26/17 was not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 65-year-old female enrollee has requested reimbursement for Cx Bladder testing performed on 7/02/18. 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 records document asymptomatic microscopic hematuria. Cxbladder testing is not a screening test for urothelial cancer in patients with hematuria. Cystoscopy and possible biopsy and upper tract imaging may still be necessary regardless of the results of Cxbladder testing. Urinary biomarker tests such as Cxbladder testing may provide false-negative results in patients with bladder cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors. To date, there are multiple urine markers that have improved sensitivity over cytology, but there is lack of validation of clinical utility. Some of the recently developed markers aim to change the paradigm of urothelial diagnosis and follow-up by replacing or reducing the need of invasive investigations. However, further prospective validations are needed to confirm these findings. Therefore, Cxbladder testing performed on 7/02/18 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 65-year-old female enrollee has requested reimbursement for Cx Bladder testing performed on 7/02/18. 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 there is a lack of support for the services at issue in this patients case. The records document microscopic hematuria. She had a normal cystoscopy and normal renal ultrasound. The patient has a history of cirrhotic liver secondary to alcohol without cirrhosis. Selective use of Cxbladder testing to decipher equivocal diagnostic findings in microscopic hematuria evaluation is currently in clinical use, but there is a lack of evidence in the literature or clinical practice guidelines that supports a role for Cxbladder testing after standard testing with cystoscopy and initial upper tract imaging is entirely normal. Current guidelines do not support the services at issue as beneficial beyond standard diagnostics in this setting. In sum, Cxbladder testing performed on 7/02/18 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 65-year-old female enrollee has requested reimbursement for Cx Bladder testing performed on 7/02/18. 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 there is insufficient support for the services at issue in this clinical setting. Establishment of bladder cancer diagnosis and the evaluation of microscopic hematuria for asymptomatic patients include imaging, cystoscopy and cytology. This patient was evaluated for microscopic hematuria with negative cystoscopy. Therefore, further testing with urine biomarkers was not indicated. At this time, the superior efficacy of the services at issue has not been established. Thus, Cxbladder testing performed on 7/02/18 was not likely to have been more beneficial than other methods of evaluating this patient.