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

Summary Reviewer 

The patient is a 65-year-old male with a history of melanoma involving the right axillae. He has a history of a melanoma in the chest in 2016. The physician reviewer found that the National Comprehensive Cancer Network guidelines recommend that patients with metastatic melanoma have tissue sent to ascertain alterations in BRAF, and in the appropriate clinical setting, KIT from either biopsy of the metastasis (preferred) or archival material, if the patient is being considered for targeted therapy. Consideration of broader genomic profiling is recommended if the test results might guide future treatment decisions or eligibility for participation in a clinical trial. Given the patients advanced disease, molecular profiling was medically indicated. Therefore, targeted genomic sequence analysis, DNA 324 genes (0037U) performed on 2/20/19 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 48-year-old female enrollee has requested reimbursement for genetic testing performed by Myriad Laboratories on 10/4/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for breast or ovarian cancer syndrome. The physician reviewer found that per the National Comprehensive Cancer Network (NCCN) guidelines, a first degree relative with ovary cancer, such as this patient, qualifies for BRCA testing, which was approved. However, there is a lack of scientific data to support the remaining portions of the genetic testing performed in this patients evaluation. Therefore, the genetic testing performed by Myriad Laboratories performed on 10/4/17 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 48-year-old female enrollee has requested reimbursement for genetic testing performed by Myriad Laboratories on 10/4/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for breast or ovarian cancer syndrome. The physician reviewer found that there is currently a lack of prospective randomized controlled studies showing improved outcomes with use of genetic testing in this setting. There is a paucity of data from clinical trials correlating the results obtained from similar tests with improved overall survival, progression free survival, or quality of life. Further, the National Comprehensive Cancer Network (NCCN) and American Society of Clinical Oncology (ASCO) guidelines encourage research to delineate the optimal use of panel-based testing, development of evidence-based practice guidelines as data emerges, and education of providers regarding challenges in the use of these tests (Daly, et al; Robson, et al). In the absence of data demonstrating improved health outcomes with use of these tests, the genetic testing performed by Myriad Laboratories performed on 10/4/17 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 48-year-old female enrollee has requested reimbursement for genetic testing performed by Myriad Laboratories on 10/4/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for breast or ovarian cancer syndrome. The physician reviewer found that this patient has several close relatives with cancers suggestive of a genetic cause for malignancy. The patient may have inherited a mutation from her paternal side, given her sister and cousins with breast cancer. Based on this, she meets the National Comprehensive Cancer Network (NCCN) guidelines for genetic testing. The largest studies reporting on the outcomes of multigene testing indicate that among women tested in clinical settings, about 5-10% have a BRCA1 or BRCA2 mutation, and about 4-7% have a harmful mutation in another gene associated with high to moderate risks of breast and/or ovarian cancer. Thus, the genetic testing performed by Myriad Laboratories performed on 10/4/17 was 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 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 


A 33-year-old male enrollee has requested reimbursement for residential treatment center (RTC) services provided from 6/11/17 through 7/2/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found that based on the available documentation, the services provided from 6/11/17 through 7/2/17 were medically necessary for treatment of this patients schizoaffective disorder and stimulant use disorder. The RTC services could not have been adequately and effectively delivered in a less restrictive setting. The patients debilitating formal thought disorder fueled impairment in all functional domains. He was treated with a relatively high dose of clozapine, which is a complex antipsychotic typically reserved for the most refractory of cases. In addition to his psychosis, the patient had co-occurring depression, anxiety, addictive illness and thyroid disease and history of multiple psychiatric hospitalizations including prior admissions during the episode of illness. On 6/11/17, the patient was mildly anxious and labile. His insight and judgment were both impaired. He reported suicidal ideation and auditory hallucinations. He had recently relapsed on methamphetamine. Given these reports, the patient had not yet consolidated the treatment gains necessary to succeed in the outpatient setting. However, the patient remained engaged in active treatment. He was described by staff as depressed, lethargic, flat, constricted and distracted. He had frequent auditory hallucinations. He had thought blocking on 6/29/17. Further, he was experiencing sedation with the increasing doses of clozapine and amitriptyline. During the disputed timeframe, the residential setting was reasonably expected to improve the patients condition and prevent a more serious episode of illness. The duration of services was consistent with community standards for a case of this complexity. Considering the chronicity and severity of the disease burden, the RTC services provided from 6/11/17 through 7/2/17 were medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were 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 64-year-old male enrollee has requested authorization and coverage for Xiaflex (clostridial collagenase histolyticum) injection. The Health Insurer has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees Peyronies disease.The physician reviewer found that Peyronies disease is caused by scar tissue, called plaque, which forms along the length of the penis in the corpora cavernosa. This plaque is not visible, and depending on the severity of the condition, this condition can cause penile curvature with erection. The curvature can make intercourse difficult and/or painful for the patient and his partner. Potential treatments for Peyronies disease include surgery, minimally invasive treatment options, and medication. The results of most available medications have been inconsistent or lacked empirical support for effectiveness; however, Xiaflex injections have the potential to significantly reduce penile curvature in this setting. CCh (Xiaflex) is a purified mixture of AUX-I and II collagenases. Medical studies have shown this therapy to be a minimally invasive treatment for Peyronies disease. Findings from IMPRESS (Investigation for Maximal Peyronie's Reduction Efficacy and Safety Studies) I and II, 2 independent, double-blind, placebo controlled studies, reveal the efficacy and tolerability of CCh for improving the physical and psychological outcomes of Peyronies disease. The two studies examined collagenase injections in 832 patients with moderate to severe curvature from Peyronies disease. Patients treated with collagenase injections had 34% improvement in penile curvature compared to 18% in the placebo group (Gelbard et al).  A follow-up open label study who received placebo also showed good outcomes with this therapy (Levine et al). American Urological Associations Peyronies disease guidelines from 2015 state: Clinicians may administer intralesional collagenase clostridium histolyticum in combination with modeling by the clinician and by the patient for the reduction of penile curvature in patients with stable Peyronies disease, penile curvature >30 and <90, and intact erectile function (with or without the use of medications). (Moderate Recommendation; Evidence Strength Grade B). Furthermore, EAU guidelines consider intralesional collagenase one of the recommended treatments for non-operative treatment of Peyronies disease. Moreover, intralesional injection therapy with CCH has been approved by the Food and Drug Administration (FDA) for the treatment of adult men with Peyronies disease with a palpable plaque and curvature deformity of at least 30 degrees at the start of therapy. In this patients case, the submitted documentation demonstrates that he is an appropriate candidate for Xiaflex and therefore Xiaflex is medically necessary for treatment of his medical condition. Based on the reasons stated above, the requested therapy 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 50-year-old female enrollee has requested reimbursement for laboratory services (82306) provided on 6/26/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollee, who has a history of anxiety, depression, insomnia and attention deficit disorder. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient has a history of depression, anxiety, attention deficit disorder and insomnia. The psychiatric literature does not support the use of testing for vitamin D or supplementation of vitamin D for psychiatric conditions. It is not clear that the patient has had cognitive behavioral therapy (CBT) for her major depressive disorder or anxiety disorder diagnoses.  It is not clear that the patient has tried other forms of psychotherapy that have been shown to be effective for her diagnoses. CBT is a first-line treatment for the patients conditions. Vitamin D testing was not an evidence-based treatment approach in this patients case. All told, laboratory services (82306) provided on 6/26/18 were not medically necessary for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 65-year-old female enrollee has requested authorization and coverage for Prolia. The Health Insurer has denied this request and reported that the requested medication is 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 requested medication. 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 which 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 for patients who have failed or are intolerant to other available osteoporosis therapy. Therefore, Prolia is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a seven-year-old female enrollee has requested authorization and coverage for Avastin (bevacizumab). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees glioblastoma multiforme. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested medication. Brainstem gliomas are aggressive and chemotherapy options are limited. These tumors are very rare so the studies available in the medical literature are small and limited. Nevertheless, medical studies indicate that Avastin use is safe and effective. Importantly, Avastin is being used upfront along with radiation therapy where it may also have steroid-sparing function. Given the lack of standard options available to this patient, Avastin is clinically indicated. Therefore, the request for Avastin is medically necessary and appropriate in this patients case. For the reasons provided, 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 

A 25-year-old transgender male enrollee has requested authorization and coverage for top surgery (mastectomy). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. World Professional Association for Transgender Health (WPATH) states that social transition is not a requirement before chest surgery for transgender men. The one year of social transition is only a requirement for reconstructive genital surgery. In fact, chest surgery often is the first medical procedure for transgender men, before hormones, and before the person first presents publicly as male. Distress is often high in young transgender men, and chest surgery for transgender men has been demonstrated to reduce distress. Olson-Kennedy and colleagues noted chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. There is sufficient support for the requested services in this clinical setting. Therefore, top surgery (mastectomies) is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 57-year-old female enrollee has requested reimbursement for the DecisionDx-Melanoma Assay provided on 7/20/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that there is a lack of support for the services at issue in this patients case. DecisionDx-Melanoma Assay is a gene expression profile test which was designed to predict distant metastasis in stage I and stage II melanoma patients. DecisionDx-Melanoma assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class 1 (i.e., low risk of metastasis) or Class 2 (i.e., high risk of metastasis). At this time, the medical evidence has not demonstrated the superior efficacy of the services at issue. There is a lack of peer-reviewed published studies demonstrating that the DecisionDx-Melanoma Assay is superior over other modalities in this clinical setting. Therefore, DecisionDx-Melanoma Assay performed on 7/20/18 was not likely to have been more effective than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 57-year-old female enrollee has requested reimbursement for the DecisionDx-Melanoma Assay provided on 7/20/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that Mucosal melanoma is rare and accounts for only 1% of all melanomas. Mucosal melanoma carries a worse prognosis than cutaneous melanoma. The information obtained from the DecisionDx-Melanoma Assay for this patient with negative sentinel lymph node biopsy results and intermediate thickness tumor on the mucosa may be beneficial. The results of the DecisionDx-Melanoma Assay may help determine the need for follow-up examination, including imaging, which will need to be made on an individual basis for this patient, as her disease is rare. Given her age, the value of the sentinel lymph node biopsy is not as predictive, as sentinel lymph node biopsy is more frequently negative in older patients. In sum, DecisionDx-Melanoma Assay performed on 7/20/18 was likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 57-year-old female enrollee has requested reimbursement for the DecisionDx-Melanoma Assay provided on 7/20/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma. The physician reviewer found the medical evidence does not support the superior efficacy of the services at issue in this patients case. The records document melanoma of 1.02 mm Breslow depth on the left labia. The National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma Assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in this clinical setting. DecisionDx-Melanoma Assay is not expected to impact the treatment or outcome of the patients melanoma. Thus, DecisionDx-Melanoma Assay performed on 7/20/18 was not likely to have been more efficacious than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 61-year-old female enrollee has requested reimbursement for Collagen Type 1 C-telopeptide blood test that was performed on 11/21/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees post-menopausal osteoporosis. The physician reviewer found osteoporosis is a condition of thinning of the bones which leads to increased risk of fracture. It is defined by the World Health Organization (WHO) as a bone mineral density of 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults) as measured by dual-energy X-ray absorptiometry. Bone mineral density (BMD) assessment, via DEXA, is still the criterion standard for evaluation and diagnosis of osteoporosis. However, because changes in bone mass and density in response to antiresorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover, (proteins and peptides, referred to as biochemical bone markers, that are released as a consequence of the physiological action of osteoblasts and osteoclasts) may be a useful adjunct in monitoring of osteoporotic patients treated with antiresorptive agents (Eastell et al). Medical evidence suggests that biochemical markers could be useful in making therapeutic decisions because, in general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine (Chestnut et al).  For this reason, the Centers for Medicare and Medicaid Services (CMS) has established a national policy for reimbursement of collagen crosslink testing including indications such as identifying individuals with elevated bone resorption, who have osteoporosis in whom response to treatment is being monitored and predicting response to Food and Drug Administration approved antiresorptive therapy in postmenopausal women. In sum, the disputed testing was clinically appropriate and indicated for evaluation of the patients medical condition.
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 2


A 61-year-old female enrollee has requested reimbursement for Collagen Type 1 C-telopeptide blood test that was performed on 11/21/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees post-menopausal osteoporosis. The physician reviewer found per the National Osteoporosis Foundation guidelines, biochemical markers of bone turnover may predict the following: risk of fracture independently of bone density in untreated patients; rapidity of bone loss in untreated patients; the extent of fracture risk reduction when repeated after 36 months of treatment with Food and Drug Administration (FDA) approved therapies; help determine adequacy of patient compliance and persistence with osteoporosis therapy; and help determine duration when and if medication should be restarted.In this patient, the biochemical marker of bone turnover Collagen Type 1 C-telopeptide, aids the physician in risk assessment and serves as an additional monitoring tool when treatment is initiated (Cosman et al and Burch et al). The change in biochemical markers can be seen sooner than the expected change in bone mineral density. The standard of care is to normally order this test as part of the assessment of patient compliance and effect of medication on bone turnover. It is widely used by endocrinologists and experts in osteoporosis management to assess the effect of therapy as delineated above. This test, Collagen Type 1 C-telopeptide, was appropriately ordered for this patient as part of her osteoporosis management.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.