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

Summary Reviewer 1

A 34-year-old female enrollee has requested authorization and coverage for BRCA testing. The Health Insurer has denied this request indicating that the requested testing is considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found the requested testing is likely to be more effective for this patient than other available treatment options. In this case, the patient meets the National Comprehensive Cancer Network (NCCN) guidelines as she has a second degree relative diagnosed with breast cancer at age 45. In addition, she has no living affected relatives who can be tested. Therefore, BRCA genetic testing is 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 requested testing is 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 34-year-old female enrollee has requested authorization and coverage for BRCA testing. The Health Insurer has denied this request indicating that the requested testing is considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found the request for BRCA genetic testing is likely to be more effective for this patient than other available treatment options. The patient meets National Comprehensive Cancer Network (NCCN) guidelines for BRCA testing given that she has more than two relatives on the same side of the family with breast cancer. If she were to harbor a BRCA mutation then prophylactic surgeries or heightened screening could be pursued to lower her risk of breast and/or cervical cancer. As such, BRCA genetic testing is clinically indicated and 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 requested testing is 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 34-year-old female enrollee has requested authorization and coverage for BRCA testing. The Health Insurer has denied this request indicating that the requested testing is considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found the BRCA testing is important in clinical oncology because bilateral mastectomy would eliminate a carriers chance of developing breast cancer. At the present time genetic testing is not applied universally but rather to patients that exhibit family histories that are suggestive of inherited predispositions (U.S. Preventative Services Task Force; Frank, et al). A study by Frank and colleagues performed BRCA testing in 10,000 individuals and related the presence of mutations to the family history. The authors found that family history included at least one first or second degree relative with breast or ovarian cancer.  In this case, the patient does not have breast cancer but the best method for surveillance cannot be determined without knowing her BRCA mutation status. She has two second degree relatives with cancer, this history alone would not mandate magnetic resonance imaging (MRI) based breast cancer exams, but MRI would be indicated if she was found to be a BRCA mutation carrier. As such, BRCA testing is medically appropriate and likely to be more beneficial for evaluation of the patients medical condition than other modalities. Based upon the information set forth above, the requested testing is 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 1


A 49-year-old male enrollee has requested reimbursement for Oncotype DX Colon Cancer Assay performed on 5/29/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the use of 12-gene expression test (Oncotype DX Colon Cancer Assay) is unproven for predicting the likelihood of disease recurrence in patients with stage II colon cancer following surgery. There is a lack of prospective randomized solid phase II or III data to warrant its routine use.  Until prospective randomized data is published, the superior efficacy of the services at issue cannot be established.  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 Upheld

Summary Reviewer 2


A 49-year-old male enrollee has requested reimbursement for Oncotype DX Colon Cancer Assay performed on 5/29/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the current medical evidence has not demonstrated the superior efficacy of the services at issue.  Clinical validation has shown that recurrence scores are prognostic for survival, recurrence and disease-free survival, but are not predictive of response to adjuvant therapy.  Thus, there is a lack of support for the services at issue to predict response to chemotherapy.  At this time, the services at issue are not standard of care.  In sum, Oncotype DX Colon Cancer Assay performed on 5/29/14 was not likely to have been more effective 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 Upheld

Summary Reviewer 3


A 49-year-old male enrollee has requested reimbursement for Oncotype DX Colon Cancer Assay performed on 5/29/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.The physician reviewer found the medical evidence shows that adjuvant chemotherapy confers a survival advantage for patients with stage III colorectal cancer, but not for those with stage II disease.  The reasons for this conclusion are complex. Stage II patients do well after surgery alone so that the magnitude of the survival benefit conferred by adjuvant chemotherapy is small; and, randomized clinical trials to date have had too few stage II patients to discern a statistically significant advantage.  Therefore, subset analyses to identify those patients with prognostic features that may predict for chemotherapy benefit have been analyzed. For example, oncologists consider adjuvant treatment for those stage II patients with T4 disease, obstructing lesions, and other biomarkers.  The Oncotype DX test uses a reverse transcriptase-polymerase chain reaction assay for 12 genes in an algorithm that can be used to predict recurrence. The test was validated independently as being an excellent prognostic indicator. It remains an open question whether adjuvant chemotherapy can obviate recurrence risk. Nevertheless, the medical evidence for the test is sufficient to allow its use to estimate the risk of recurrence for stage II patients and incorporated with other tests such as standard pathology and microsatellite instability testing.  Thus, Oncotype DX Colon Cancer Assay performed on 5/29/14 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 Upheld

Summary Reviewer 1
A 56-year-old male enrollee has requested reimbursement for DecisionDX-Melanoma test performed on 8/4/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma The physician reviewer found the prognosis of cutaneous melanoma has traditionally been determined by the staging system reported by Balch and colleagues. Mitotic index has also been demonstrated to support these statistics. DecisionDX is a study of 31 genes in the melanoma cells. It then classifies that particular melanoma as either Class 1, with a 97% disease free rate at five years or Class 2 with a 31% disease free rate at five years. A study by Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDX classification in patients with negative sentinel nodes. However, the medical studies are not clear how DecisionDX data compares to the ten year data of the Balch tables, and whether it can be used to make clinical decisions. This is particularly true in this patient, who has an expected excellent survival rate. Moreover, the National Comprehensive Cancer Network (NCCN) guidelines state that while there is some interest in these newer genetic profiles, these tests are only performed in the context of a clinical trial. Therefore, DecisionDX-Melanoma test performed on 8/4/15 was not expected to be of superior clinical benefit than available standard modality used for evaluation of this patient. 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 2


A 56-year-old male enrollee has requested reimbursement for DecisionDX-Melanoma test performed on 8/4/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma] The physician reviewer found the current standard of care, based on National Comprehensive Cancer Network Guidelines (NCCN) guidelines, uses the tumor node metastasis (TNM) cancer staging system to determine a recommendation for additional imaging tests or for additional treatment. The NCCN guidelines state that there is an interest in newer prognostic molecular techniques such as gene expression profiling to determine low versus high risk for metastases. However, routine baseline genetic testing of primary cutaneous melanoma is not recommended outside of a clinical trial. As such, in this patients case, the use of DecisionDX-Melanoma assay was not likely to be more effective than available standard staging systems for the evaluation of this patient. 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

A 56-year-old male enrollee has requested reimbursement for DecisionDX-Melanoma test performed on 8/4/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma The physician reviewer found the medical studies have shown 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 they suggest a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. In this patients case, a sample of his tumor was sent for DecisionDX-Melanoma testing. However, there is very little data on the DecisionDX-Melanoma test. The available studies are unclear as to how to incorporate this assay into the treatment algorithm beyond standard staging techniques. This was also the consensus opinion of the National Comprehensive Cancer Network guidelines. As such, the medical data available does not support the superior efficacy of DecisionDX-Melanoma, performed on 8/4/15, over other standard methods of staging for the evaluation of this patients tumor.  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 1

A 22-year-old male enrollee has requested reimbursement for (81229) cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities on 3/16/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees behavioral health condition. The physician reviewer found that the medical evidence does not support the superior efficacy of the services at issue in this patients case. Ordering single nucleotide polymorphism (SNP) microarray analysis is not standard of care for patients with a diagnosis of schizophrenia, depression, or bipolar disorder. These disorders have complex genetics, and the current literature shows that the genetics of bipolar, depression, and schizophrenia are not fully understood. Moreover, there are many different genetic malformations that can lead to the same phenotype. Studies have found common genetic variants for those with bipolar disorder and schizophrenia, but many of these variants are not consistent. Diagnosing a patient with bipolar, schizophrenia, or depression based on SNP microarray analysis is not reliable and not standard of practice. Even if a patient were to have an abnormal SNP microarray analysis, these diagnoses are made by clinical evaluation and criteria. All told, cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and SNP variants for chromosomal abnormalities on 3/16/16 were not likely to have been more effective than the standard options for the evaluation of this patient. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 22-year-old male enrollee has requested reimbursement for (81229) cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities on 3/16/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees behavioral health condition. The physician reviewer found that there is a lack of evidence based literature that show the efficacy of genetic testing in evaluating patients  diagnosed with bipolar disorders or ADHD. There is very limited clinical justification, based on substantial medical research, to endorse genetic screening tests prior to attempting another medication for treatment of ADHD, bipolar disorder, or personality disorders.  Specifically, the standard of care for treatment of these disorders would be to continue to trial or prescribe stimulant medication. This method of prescribing medication would produce similar outcomes when compared to awaiting genetic testing results in this patients case.  In sum, cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and SNP variants for chromosomal abnormalities administered on 3/16/16 were not likely to have been more effective than the standard options available for the evaluation of this patient. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 22-year-old male enrollee has requested reimbursement for (81229) cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities on 3/16/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees behavioral health condition. The physician reviewer found that there is a lack of support in the medical literature for the services at issue in this clinical setting. Studies have shown that clinically useful predictors in genetic testing are scarce with results being inconsistent and only marginal clinical association between enzyme system variants and drug metabolism, efficacy, and tolerability. There is a lack of large randomized trials to support its use in this patients case.  The existing studies have also indicated that there is no significant correlation between either genotypes or medication serum concentration and response to treatment.  Current evidence does not support the use of genotyping when choosing an antidepressant, and even less is understood about its use in the treatment of anxiety disorders.  Genetic testing, used in this clinical setting, lacks evidence based research to show its effective use in guiding a clinician towards choosing a medication regimen.  As such, (81229) cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism variants for chromosomal abnormalities administered on 3/16/16 were not likely to have been more effective than the standard options for evaluating this patient. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 19-year-old male who has a long history of back and shoulder pain. He has been seen by a chiropractor on multiple occasions and has been treated conservatively. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. Pain is a common complaint, and not everyone who has pain needs a CT or MRI scan. As a fundamental principle, an imaging study is only worthwhile if it will affect the management of the patient. In this patient, especially considering the negative thoracic spine CT scan, the likelihood of detecting a significant abnormality that would have changed the management was minimal. The fact that the patient had a negative CT scan of the thoracic spine would exclude likely culprits (in a patient of this age) such as a scoliosis, mild degenerative change, or anatomic variations such as a hemivertebral body. In the absence of any of these findings, especially in a young active patient who has a recent history of hurting his back after playing sports, the likelihood of MRI providing any significant information is minimal.
As has been shown in multiple studies, incidental finding of degenerative disease or disc abnormality is exceedingly common in asymptomatic individuals. It is well known that some patients with substantial MRI findings will not have symptoms, and conversely, some patients with minimal signs on MRI will have pronounced symptoms. The American College of Radiology has established aAppropriateness Criteriaa to help referring physicians obtain efficient use of imaging modalities to evaluate various clinical presentations. While they have not established specific criteria for thoracic spine pain, they have established these criteria for chronic neck and low back pain. MRI is felt to be anot usually appropriatea in the management of chronic pain without other red flags. This patient had no symptoms other than pain, which he reports having had for at least the last year. There is no evidence of radiculopathy, prior tumor, or infection. The medical evidence does not support the services at issue in this patientas case. Therefore, the MRI performed on 7/01/20 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1
A 52-year-old male requested authorization and coverage for hypoglossal stimulator.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea. The physician reviewer found that the patient has been diagnosed with obstructive sleep apnea (OSA). The sleep study that is available is over eight years old and it shows only hypopnea events with no obstructive apnea events. The patient has failed Provent, CPAP, BiPAP, and dental device. The Inspire device is U.S. Food and Drug Administration approved for the treatment of OSA when certain criteria are met. However, this patients sleep study is over eight years old. As such, the documentation is lacking to support the superior efficacy of the requested services over the standard options available for treating this patients medical condition.

Therefore, for the reasons stated above, the requested services are 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.