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

Summary Reviewer 3


A 44-year-old female enrollee has requested reimbursement for Prometheus testing performed on 4/30/15.  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 in this case, testing was ordered to determine the etiology for possible loss of response to Humira and to direct the management of the patients ulcerative colitis. The effectiveness of the testing at issue compared with conventional courses of action, for example change of dose or change of medication, remains unproven.  The published studies on the use of anti-adalimumab antibodies and serum levels are small and retrospective and/or observational in nature. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking.  For these reasons, there is not sufficient evidence to demonstrate the superior efficacy of the service at issue.  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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 51-year-old male enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation from 8/08/16 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 conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  It is uncertain if this patients current symptoms are due to a substance induced mood disorder.  One of his previous depressive episodes was likely brought on by methamphetamine abuse.  There was no documentation of a negative urine drug screen.  There is a lack of robust studies showing improvement in patients with major depressive disorder and comorbid posttraumatic stress disorder.  Flory and Yehuda reported that patients with posttraumatic stress disorder and comorbid major depressive disorder have a high likelihood for poor response to treatment.  The treatment recommendation for major depressive disorder with comorbid posttraumatic stress disorder is trauma-based psychotherapy.  All told, transcranial magnetic stimulation from 8/08/16 forward was not and is not medically indicated for the treatment of this patient.  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 58-year-old female with osteoporosis. The patient has requested reimbursement and prospective authorization and coverage for Prolia injections provided from 11/19/20 forward. The Health Insurer has denied this request and reported that the medication at issue was not and is not medically necessary for the treatment of this patient.  The physician reviewer found that Osteoporosis is an increasingly widespread condition. Fractures are the most dangerous aspect of osteoporosis and can lead to acute and chronic pain. A newer medication, denosumab (Prolia) is a fully human monoclonal antibody that has been approved for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone. Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapy. In this case, the patient has an increased risk of fracture, with a lowest T-score of -3.2 on 10/14/20. There is sufficient support for the medication at issue in this clinical setting. Therefore, Prolia injections provided from 11/19/20 forward were and are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 54-year-old female enrollee has requested reimbursement for left and right eye refraction surgery performed on 9/19/16 and 10/07/16. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollee, who has a history of blurred vision. The physician reviewer found that the submitted submitted documentation supports the medical necessity of a portion of the services at issue. The records show that the patient did have symptomatic cataracts requiring surgery. The Health Insurers argument that the surgery was purely for refractive reasons was not substantiated upon reviewing the medical records. Thus, the portion of surgeries to treat cataract was medically necessary. The additional treatments of femtosecond laser and multifocal intraocular lens were for the purpose of refractive treatment and were not medically necessary. Therefore, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 51-year-old male enrollee has requested authorization and coverage for acute rehabilitation inpatient services. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees status post left-sided hemilaminectomies, facetectomy, and discectomy at L2-3. The physician reviewer found the review of the submitted documentation and relevant literature demonstrated the medical necessity for the requested services. According to the documentation submitted for review, the patient has acute neurological deficits with impaired functional mobility and self-care. The patient is willing and able to participate in physical and occupational therapies. In addition, the patient requires the close medical supervision of a rehabilitation physician to monitor the acute neurologic deficits and adjust treatment accordingly. For the reasons provided, acute rehabilitation inpatient services are medically necessary for treatment of the patients medical condition. For the reasons provided, the requested services 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 

A 47-year-old female enrollee has requested authorization and coverage for treprostinil (Orenitram) tablets. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees pulmonary arterial hypertension. The physician reviewer found the U.S. Food and Drug Administration (FDA) indicates that Orenitram is a prostacyclin vasodilator indicated for treatment of PAH with WHO Group 1 to improve exercise capacity. The study that established effectiveness included predominately patients with WHO functional class II-III symptoms. This patient has been diagnosed with PAH consistent with WHO Group 1, NYHA functional class III. The patient underwent reactive testing, which was consistent with the etiology of PAH. The patient underwent the appropriate testing and was considered to be a candidate for Orenitram. All told, Orenitram is FDA approved for treatment of this patients medical condition and the literature supports the requested therapy for use in this clinical setting. Thus, the requested Orenitram is medically necessary for treatment of this patients PAH. Based on the foregoing discussion, the requested medication is 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


A 41-year-old female enrollee has requested reimbursement for a dopamine transporter single-photon emission computed tomography (DAT-SPECT) scan performed on 9/17/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of tremor. The physician reviewer found that DAT-SPECT scanning has high sensitivity and specificity relative to differentiation between Parkinsons disease and other forms of tremor.  However, it does not well correlate with treatment options which would depend upon the results of this testing.  The diagnosis of essential tremor had been well-established in this case based on the response to propranolol with very little documented evidence of a parkinsonian syndrome.  Accordingly, the DAT-SPECT scan performed on 9/17/15 was not 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 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


A 41-year-old female enrollee has requested reimbursement for a dopamine transporter single-photon emission computed tomography (DAT-SPECT) scan performed on 9/17/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of tremor. The physician reviewer found that while a DAT-SPECT study is not indicated for all patients with a hand tremor, it has been shown to be useful in cases where the diagnosis of essential tremor and Parkinsons disease are both being considered and cannot be differentiated based on clinical grounds.  In this patients case, her provider suspected a possible essential tremor (or other tremor disorder).  It is imperative to provide a definitive diagnosis as treatment for essential tremor and Parkinsons disease are quite different, and the treatments for Parkinsons disease can have significant side effects.  In this particular case, the patients diagnosis was confirmed using this study and the patient was able to be appropriately counseled.  Therefore, DAT-SPECT scan performed on 9/17/15 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


A 41-year-old female enrollee has requested reimbursement for a dopamine transporter single-photon emission computed tomography (DAT-SPECT) scan performed on 9/17/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of tremor. The physician reviewer found that the current medical evidence supports the services at issue in this clinical setting.  The patient presented with tremor and posture elements that raised question of a movement disorder condition.  There is sufficient support for DAT-SPECT scan in this case, as it could help confirm a diagnosis and provide treatment guidance given the clinical diagnosis was not clear regarding the type of movement disorder.  Thus, DAT-SPECT scan performed on 9/17/15 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 1

A 64-year-old female enrollee has requested reimbursement for genetic testing performed on
1/27/20. 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 Guardant360 is a multigene assay done from circulating DNA in blood. It is capable of reliably
detecting tumor-related genetic mutations and molecular abnormalities. The issue is whether such
an assay can direct therapy to a clinically beneficial and reliable degree. Thus far, there has been
a lack of convincing evidence that the Guardant360 assay is likely to be clinically beneficial in the
treatment of breast cancer. Finding a mutation does not guarantee that a treatment directed at that
atargeta will be successful. The likelihood of benefit from using therapy based on genomic assay
is small. Therefore, genetic testing performed on 1/27/20 was not likely to have been more
beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 64-year-old female enrollee has requested reimbursement for genetic testing performed on
1/27/20. 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 understanding the molecular drivers of cancer progression and metastases is an area of ongoing
and active research, predominantly driven by the goal of identifying specific genomic aberrations
that may ultimately result in individualized cancer treatment. In addition to likely providing
prognostic information, the value of next generation sequencing to predict candidates for specific
mutation-driven treatment holds promise. Patients with inflammatory and metastatic breast
cancers benefit from next-generation sequencing to identify markers that may indicate benefit from
targeted treatment or clinical trials. Therefore, genetic testing performed on 1/27/20 was likely to
have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 64-year-old female enrollee has requested reimbursement for genetic testing performed on
1/27/20. 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 the Guardant360 test is a liquid biopsy that analyzes patient plasma for mutations in a panel of 70
genes. Von Hoff and colleagues performed a clinical study directly that compared the use of
targeted agents with conventional chemotherapy approaches. The study involved 86 patients, and
the progression-free survival (PFS) on regimen selected by molecular profiling was compared to
the 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.
In most instances of visceral disease or lymph node involvement, testing can be performed on the
excised tissue. However, in certain cases, such as bone metastases, the decalcification process
makes the material unsuitable for gene sequencing. Thus, liquid biopsy is specifically mentioned
in the National Comprehensive Cancer Network (NCCN) guidelines as an alternative approach
when the tissues are less accessible. The oncologistas progress notes indicate that the patient has
metastatic disease involving the cervical and thoracic spine. The anatomical locations are difficult
to directly sample without a significant invasive procedure with its own morbidities. Thus, the
patientas clinical situation fits the scenario outlined in the NCCN guidelines for performing the
Guardant360 test. Therefore, genetic testing performed on 1/27/20 was likely to have been more
beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 45-year-old male enrollee has requested has requested reimbursement for the testosterone pellet (Testopel) 75 mg received on 12/18/15. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees hypogonadism. The physician reviewer found that low testosterone can lead to such complications as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue (Dandona and Rosenberg). For these reasons, many providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dL (Nieschlag, et al). The general target level for testosterone ranges from 350 to 750 ng/dL, which is approximately the range for healthy, androgen-sufficient adult men. Testosterone levels should be monitored for three to six months after initiation of treatment in order to assure that the patients testosterone level is optimal and the dose of testosterone replacement therapy should be adjusted accordingly (Rivas, et al). Testopel, which measures 3 mm by 9 mm, is an implantable testosterone pellet containing crystalline testosterone which are implanted under the skin and slowly release testosterone over the course of three to six months. Benefits include relatively long duration of action and reduced risk of exposure to other individuals via skin contact (Margo and Winn). In this case, the patient was unable to remain on topical testosterone therapy, and he has derived benefit from treatment with Testopel 75 mg. Therefore, the Testopel 75 mg received on 12/18/15 has been established as medically necessary for treatment of the patients medical condition.  Therefore, the medication at issue was 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 


A 37-year-old male enrollee has requested reimbursement for small bowel overgrowth test panel (CPT codes 82491 and 91065) performed on 11/16/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found the medical literature supports the services at issue for this clinical situation. The patient presented with bloating. Bloating can be a sign of small intestinal bacterial overgrowth (SIBO). Accurate and definitive diagnosis can be difficult (Ponziani, et al). However, hydrogen breath testing is the most widely used diagnostic test for SIBO (Lacy, et al).  Testing for both hydrogen and methane increases the sensitivity of the breath test, and is a considerable improvement over hydrogen testing alone (Saad, et al; de Lacy Costello, et al). Antibiotics are necessary for treatment of SIBO. Confirmation of SIBO with breath testing avoids using empiric antibiotics for those patients who do not have SIBO, as in this case (Ponziani, et al).  Therefore, for the reasons stated above, the small bowel overgrowth test panel (CPT codes 82491 and 91065) performed on 11/16/15 was medically necessary for evaluation of this patient. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 63-year-old male enrollee has requested authorization and coverage for once a month injection of Nucala. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees asthma and eosinophilic lung disease. The physician reviewer found that the medical literature supports the requested medication in this clinical setting. In addition, this medication therapy has been given approval by the U.S. Food and Drug Administration (FDA) for the treatment of severe persistent uncontrolled asthma. The patient is greater than 12 years old and the medication has been prescribed by an allergist. The records show that this patient has asthma, which is severe. The patient has elevated blood eosinophil count, which is 150 or higher. The patient has been on maximum dose of Symbicort, which is an inhaled steroid for at least three consecutive months with no response, oral steroids (prednisone), Spiriva, and Albuterol. This patients asthma symptoms continue to be uncontrolled despite therapy and his forced expiratory volume 1 is less than 80%. The patient meets the FDA indication and criteria for the medication Nucala. As such, once a month injection of Nucala is medically necessary for treatment of this patients medical condition. Therefore, for the reasons stated above, the requested medication is 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 nine-year-old female enrollee has requested authorization and coverage for Nutropin AQ Nuspin 10. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees short stature. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this clinical setting. This patient has idiopathic short stature based on the extreme short stature, normal growth hormone test, normal insulin-like growth factor 1, poor growth velocity and absence of other etiology for short stature. The current guidelines recommend growth hormone therapy for children who have idiopathic short stature. This patient meets these criteria for treatment under the idiopathic short stature diagnosis. She is not likely to attain a normal adult height without this treatment. This patient had a poor growth velocity which greatly improved with a trial of growth hormone therapy. Therefore, Nutropin AQ Nuspin 10 is medically necessary for the treatment of this patient.