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

Summary Reviewer 

The patient is a 47-year-old female who has requested authorization and coverage for Neulasta. She underwent chemotherapy for breast cancer. The patient has requested authorization and coverage for Neulasta. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting. Neulasta has been approved by the U.S. Food and Drug Administration to decrease the incidence of infection (as manifested by febrile neutropenia) in patients with non-myeloid malignancies receiving myelosuppressive cancer chemotherapy associated with a clinically significant incidence of febrile neutropenia. The combination of Adriamycin and cyclophosphamide carries a high risk of neutropenic fever. The standard of care is administration in a dose dense fashion every two weeks with growth factor support with Neulasta. Therefore, Neulasta is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is an eight-year-old male with a medical history of congenital torticollis, gastroesophageal reflux disease, and neurofibromatosis, type I. The patientas parent has requested reimbursement for inpatient level of care provided from 5/12/21 through 5/13/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. Acute appendicitis is one of the most common sources of acute abdominal pain in children, particularly for those between 4 and 15 years of age. While the classic presentation is that of periumbilical abdominal pain that localizes to the right lower quadrant, with anorexia and fever, there are many exceptions to this presentation. Fever may or may not be present, and pain may not yet be localized early in the course of appendicitis. Physical examination findings typically include signs and symptoms of peritonitis with localization to the right lower quadrant, but this is dependent on the intra-abdominal location of the appendix. While most patients have an elevated white blood cell count, a normal value does not rule out appendicitis. Diagnostic studies include abdominal ultrasound and abdominal computed tomography (CT) scan. The usual findings on CT include an enlarged, edematous appendix, with fat stranding in the right lower quadrant indicative of adjacent inflammation. In the absence of classical findings, with up to 50% of children presenting with an atypical history, the differential diagnosis is quite broad. Management of early acute appendicitis includes intravenous fluids, antibiotics, and pain medication. Appendectomy typically occurs within the first 12-24 hours after diagnosis. Perforation can occur, and results in a much more complicated course. The outpatient laparoscopic procedure is reserved for patients with uncomplicated appendicitis. In this patientas case, given the free fluid in the pelvis, it was not completely clear if this patient had a ruptured appendicitis or not. Second, there was evidence of peritoneal abscess upon laparoscopic investigation. Patients such as this must be monitored closely postoperatively because just as often as not, the abscess fluid re-accumulates and they require additional surgical procedures, or at the very least interventional radiology placement of pigtail catheters to drain. This patient had complicated appendicitis secondary to abscess formation as well as concern for rupture. Consistent with both care guidelines and the standard of care, acute inpatient admission was medically necessary and appropriate. Therefore, inpatient level of care provided from 5/12/21 through 5/13/21 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 45-year-old female enrollee has requested reimbursement for inpatient mental health treatment from 2/08/16 through 2/11/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  However, episodic placement in more restrictive settings is often clinically appropriate for those with serious mental illness. In this case, the patient was suffering from an extraordinarily severe mental illness. The treating psychiatrist determined that the patients symptom complex could not be managed at a lower level of care.  She had a prominent illness burden and abysmal insight.  She had limited social support.  She required long-term specialty care and there was reasonable concern that discharge to home would have terminated rather than interrupted the episode of care.  The treatment was safe, appropriate and reasonably expected to prevent a worsening of illness.  All told, inpatient mental health treatment from 2/08/16 through 2/11/16 was medically indicated for the treatment of this patient.  Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 46-year-old male enrollee has requested reimbursement for the gastrointestinal (GI) effects comprehensive profile stool testing performed on 1/10/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the GI effects comprehensive profile stool testing performed on 1/10/16 was not likely to be more effective for this patient than other available options. Recommendations for the evaluation and management of irritable bowel syndrome do not support the approach prescribed for this patient. For example, a fecal calprotectin is part of the battery of tests included in the comprehensive stool analysis. This test would be potentially useful if the patient was undergoing an initial work-up. However, he already had an endoscopic work-up documenting that he does not have colitis. Given the above, the testing at issue 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 46-year-old male enrollee has requested reimbursement for the gastrointestinal (GI) effects comprehensive profile stool testing performed on 1/10/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that based on the documentation submitted for review, the GI effects comprehensive profile stool testing was not likely to be more beneficial for evaluation of the patients medical condition than standard testing. Specifically, the polymerase chain reaction (PCR) assessment of enteric pathogens and the ova and parasite components of the comprehensive profile stool testing were duplicative to studies the patient reports were already performed. In addition, the calprotectin assay was not indicated since colitis had already been ruled out by previous colonoscopy and computed tomography (CT) imaging. As such, the GI effects comprehensive profile stool testing 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 46-year-old male enrollee has requested reimbursement for the gastrointestinal (GI) effects comprehensive profile stool testing performed on 1/10/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that stool pathogen panels use of polymerase chain reaction (PCR) are not incorporated into standard medical practice. The American Academy of Family Practice guidelines for evaluation of chronic diarrhea, including investigation of suspected inflammatory bowel disease, also do not recommend stool PCR testing panels for multiple pathogens (Juckett and Trivedi). In addition, the use of calprotectin to diagnose change in bowel habits has not been recommended. Per the American College of Physicians (ACP) a specialist might measure fecal calprotectin, but only in conjunction with detailed history-taking, clinical examination, and serum inflammatory markers or other blood tests, to determine the need for endoscopic evaluation (Forbes, et al). The ACP also stated that fecal calprotectin is elevated in several other gastrointestinal diseases, including viral, bacterial, and protozoal causes of infective diarrhea (Forbes, et al). The impact of this testing on management and its appropriateness in guiding therapy decisions in patients with unexplained diarrhea has not been demonstrated. The findings can be redundant with standard methods of diagnosis, such as colonoscopy or sigmoidoscopy, or other serum markers of inflammation. Furthermore, clinical studies do not support a standardized action, such as empiric use of antibiotics or empiric therapy for inflammatory bowel disease, for a positive result. Clinical guidelines and medical literature do not definitively support the use of the testing at issue. Therefore, the GI effects comprehensive profile stool testing performed on 1/10/16 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 29-year-old male enrollee has requested reimbursement for chiropractic services provided on 2/03/16, 2/08/16 and 2/15/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees spinal enthesopathy, segmental and somatic dysfunction of cervical region, and sprain of ligaments of thoracic spine. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The clinical records do not support the need for the chiropractic services provided on 2/03/16, 2/08/16 and 2/15/16.  The records note that the patient was receiving additional units of therapy in addition to spinal and extraspinal manipulation per visit.  This is considered excessive, and the medical evidence does not support the services at issue in this clinical setting.  There is a lack of high-grade scientific evidence to support passive physical modalities such as traction and massage/myofascial release for neck and upper back complaints.  All told, chiropractic services provided on 2/03/16, 2/08/16 and 2/15/16 were not medically indicated 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

The patient is a 59-year-old female who has been diagnosed with a uterine leiomyosarcoma. She was initially diagnosed in August 2001, at hysterectomy, with the finding of a 1.5 cm leiomyosarcoma. After surgery, she received radiation therapy. She was then well until mid-2016 when a computed tomography scan revealed a pelvic mass, confirmed by positron emission tomography scan. Biopsy was positive for recurrent leiomyosarcoma. She underwent debulking surgery and was started on adriamycin with olaratumab. Her tissue was sent for FoundationOne assay. The patient has requested reimbursement for the FoundationOne test performed on 11/14/16. The Health Insurer has denied reimbursement on the basis that services at issue were investigational for the evaluation of this patients medical condition. There is a lack of support for the services at issue in this clinical setting.  FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the clinician as to which chemotherapeutic drug would be useful. However, there is a lack of convincing evidence that the assay adds to the decision making ability of the clinician, or yields a result that is reliably clinically beneficial. There are various non-randomized studies exploring the value of molecular profiling but these studies are not definitive or compelling as to the efficacy of the assay.  A randomized study by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular targets. Finding a mutation does not guarantee that a treatment directed at that mutation will produce a clinically meaningful response. All told, the FoundationOne test performed on 11/14/16 was not likely to have been more efficacious than other methods of evaluating this patients medical condition.   Therefore, for the reasons stated above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

The patient is a 59-year-old female who was diagnosed with recurrent leiomyosarcoma of the uterus. A sample tissue was sent for genetic testing. The patient has requested reimbursement for the FoundationOne test performed on 11/14/16. The Health Insurer denied this request and reported that the services at issue were investigational for evaluation of this patients medical condition. To demonstrate the clinical utility of panel genetic testing, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. At this time, there is a lack of such trials, which have been published. Currently recognized and accepted molecular evaluation and classification of soft tissue sarcoma (STS) include standard histological evaluation. Effective therapy for STS, including classification, is well summarized in the National Comprehensive Cancer Network (NCCN) guidelines. There is a lack of support in the literature for broad genomic panel testing. The available literature on clinical utility consists of a small number of uncontrolled studies and nonrandomized controlled trials that use imperfect comparators. This evidence is not sufficient to make conclusions as to the clinical utility of broad genetic testing. In addition, there is potential for harm if ineffective therapy is given based on test results because there may be adverse effects of therapy in the absence of a benefit. As a result, the use of expanded mutation panel testing for targeted treatment in cancer is considered unproven,  For these reasons, the FoundationOne test performed on 11/14/16 was not likely to have been of greater benefit than other treatment modalities for evaluating 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

The patient is a 59-year-old female who is diagnosed with uterine leiomyosarcoma. She was initially diagnosed at age 43 with stage I disease that recurred 15 years later. She was treated with doxorubicin and an anti-PDGFA antibody. A sample of the tumor was submitted for FoundationOne mutational analysis. The patient has requested reimbursement for the FoundationOne test performed on 11/14/16. The Health Insurer has denied this requested and reported that the services at issue were investigational for the evaluation of this patients medical condition. The FoundationOne test is Clinical Laboratory Improvement Amendments (CLIA) approved for use on clinical specimens. It is a next generation test that analyzes for mutations or rearrangements in approximately 400 oncogenes and tumor suppressor genes. A study by Von Hoff and colleagues involved 86 patients where the progression free survival (PFS) on the 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.  There are many parallels in the molecular genetics between soft tissue sarcomas and hematologic malignancies. For example, dermatofibrosis protuberans is characterized by recurrent translocation involving PDGFB, which may be targeted by imatinib.  There is support in the medical literature for the use of genetic testing to identify mutations that may be amenable to targeted therapies. As such, the FoundationOne test performed on 11/14/16 was likely to have been more effective than the standard techniques available for evaluating this patients medical condition. Therefore, for the reasons stated above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a now deceased female who was transported by air ambulance from Lenox Hill Hospital in New York to Providence Tarzana Medical Center in Tarzana, California on 2/24/20. The patientas representative has requested reimbursement for air ambulance transport provided on 2/24/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that in order for air medical transport to be medically necessary, specific criteria must be met. These criteria include the following: the patientas condition must be such that any form of transportation other than ambulance would be medically contraindicated; the patientas condition is such that time needed to transport by ground poses a threat to the patientas survival; the patient is transported to the nearest hospital with appropriate facilities for treatment; and there is a medical condition that is life-threatening. When transporting from one facility to another, the above criteria must be met, and the first hospital should not have the required services and facilities to treat the patient. In this case, the medical records document that the patient was transported from New York to her home state of California in order to receive continuity of care from her oncologist. This does not meet criteria for medical necessity, as the transferring facility was capable of providing the necessary care. The patient chose to be transferred to receive care from the providers she preferred. Therefore, medical necessity criteria for air ambulance transport are not met. Thus, air ambulance transport provided on 2/24/20 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The patient is a 63-year-old male with a diagnosis of benign prostatic hyperplasia (BPH). Associated symptoms include frequency, dysuria, intermittent difficulty in urinary flow, and an elevated prostate-specific antigen (PSA) of 10. A computed tomography (CT) scan of the abdomen and pelvis dated 8/21/17 showed a large prostate, thick bladder with calculi, intermittent hematuria, large calcifications, and left low pole stone and bladder stone. On 8/24/17, he underwent a prostate biopsy and a cystolitholapaxy, which revealed an enlarged prostate with a volume of 45 mL, biopsy was negative, and the bladder was moderate to severely trabeculated with multiple saccules and small diverticula with a stone of 1.5 x 2.5 cm. The patient has requested authorization and coverage for a prostatic urethral lift implant. The Health Insurer has denied this request indicating that the requested surgical procedure is considered investigational. The prostatic UroLift system is a minimally invasive approach to treating BPH that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. Recent clinical trials including prospective sham controlled randomized studies have shown that the UroLift system treatment is safe and effective in relieving lower urinary tract symptoms due to BPH without significantly compromising sexual function. Compared with standard available alternatives, the prostatic UroLift system is minimally invasive procedure without a requirement of general anesthesia and with a potentially shorter operative time. All told, the requested prostatic urethral lift implant is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested procedure is likely to be more beneficial for treatment 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

The patient is a 63-year-old male with benign prostatic hyperplasia (BPH). He was having symptoms of frequency, dysuria and intermittent stream. His prostate specific antigen (PSA) was elevated at 10. On 8/3/17, a computed tomography (CT) of the abdomen and pelvis showed a large prostate, thickened bladder and a bladder stones.  On 8/24/17, he had a transrectal ultrasound and magnetic resonance imaging (MRI) of the prostate, a prostate biopsy, cystoscopy and cystolitholapaxy. The biopsy was negative for prostate cancer. The patient has requested authorization and coverage for a prostatic urethral lift implant. The Health Plan has denied this request indicating that the requested surgical procedure is considered investigational. The UroLift procedure can provide advantages over the tradition transurethral ultrasound resection of the prostate (TURP) for an obstructing prostate causing lower urinary tract symptoms. The UroLift can be done as an outpatient, with no significant blood loss, minimal anesthesia and no catheter afterwards. Given this support, the requested prostatic urethral lift implant is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Based upon the information set forth above, the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.