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

Summary Reviewer 3

The patient is a 56-year-old male who sustained a ventricular fibrillation related cardiac arrest in the setting of an acute anterior ST-elevation myocardial infarction. The patient was hospitalized from 7/31/16 through 8/05/16.  He was successfully resuscitated and treated with drug eluting stent to the left anterior descending artery. Following the procedure, additional episodes of ventricular fibrillation were documented, and he was treated with cardioversion and amiodarone. Thrombus was noted at the site of the recent left anterior descending artery stent placement which was treated with angioplasty, and critical right coronary artery lesion was subjected to percutaneous coronary intervention/stenting. The ejection fraction following the procedure was 47%. The patient has requested reimbursement for wearable cardioverter defibrillator. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of this patient.  The medical evidence has not demonstrated the superior efficacy of the device at issue in this patients case. There is a lack of support for an improvement of health outcomes when a wearable cardioverter defibrillator is deployed in this clinical setting. Implantable cardioverter defibrillator placement can be undertaken 90 days after a percutaneous coronary intervention/stenting procedure if the ejection fraction remains below 35 percent or 40 days after a myocardial infarction if there is no intervention and the ejection fraction remains below 35 percent.  There is lack of support for the device at issue in this case. Thus, the wearable cardioverter defibrillator was not likely to have been more effective than other treatment modalities. Based upon the information set forth above, the device at issue was 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.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 58-year-old male enrollee has requested authorization and coverage for intravenous immune globulin. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees myasthenia gravis. The physician reviewer found that Myasthenia gravis affects the neuromuscular junction. Patients can have weakness of the ocular, limb, respiratory, and bulbar muscles.  The nature of the pathogenesis (antibody mediated disease process) and the anatomical target can create clinical situations that are very diverse. Patients can have mild symptomatology with mild weakness or cosmetic changes to very severe life threatening clinical scenarios involving difficulty with breathing, ambulating, eating, and speaking. Treatment of myasthenia gravis is dependent on several factors including, but not limited to, the patients medical comorbidity, age, involvement of respiratory or bulbar muscles, progression, and severity. This patient has a form of myasthenia gravis that has been resistant to several therapies, including prednisone, plasmapharesis, azathioprine, mycophenolate mofetil, cyclosporine, and rituximab. Despite the significant number of medications the patient has failed, there are several therapeutic options that have shown to be effective in maintenance therapy for myasthenia gravis which have not been attempted, including tacrolimus, methotrexate, and cyclophosphamide. While intravenous immunoglobulin can be considered in severe refractory myasthenia gravis, there is a lack of evidence to suggest that intravenous immune globulin is more effective than these other agents which the patient has not tried. Therefore, intravenous immune globulin is not likely to be more effective than other treatment options. Based upon the information set forth above, the requested medication is 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.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 58-year-old male enrollee has requested authorization and coverage for intravenous immune globulin. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees myasthenia gravis. The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. There are several reports of non-controlled studies which demonstrated a benefit from the use of intravenous immune globulin in some patients with myasthenia gravis as a maintenance therapy. In this case, the patient developed severe myasthenia gravis that failed to respond to several immunosuppressive drugs. The patient has been stable while on intravenous immunoglobulin. In sum, intravenous immune globulin is likely to be superior over other treatment options in this patients case. Based upon the information set forth above, the requested medication 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 3

A 58-year-old male enrollee has requested authorization and coverage for intravenous immune globulin. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees myasthenia gravis. The physician reviewer found that this patient has tried multiple therapies for myasthenia gravis, including multiple immunomodulators. He has been hospitalized due to exacerbation. These events have potential morbidity associated with them. In this case, intravenous immune globulin treatment on periodic basis helps the patient avoid hospitalization. Thus, intravenous immune globulin is likely to be more efficacious than other treatment options. Based upon the information set forth above, the requested medication 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 26-year-old female enrollee has requested reimbursement for bilateral breast implant removal performed on 5/7/15. The Health Insurer has denied this request indicating that the procedure at issue was not medically necessary for treatment of the enrollees capsular contracture of breast implant. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the procedure at issue. According to Handel and colleagues It has become increasingly apparent in recent years that breast implant recipients experience a significant incidence of complications and a relatively high rate of reoperation. In large-scale follow-up studies conducted by manufacturers, it was reported that by the end of 5 years, women undergoing augmentation with saline-filled implants had a 10 percent rate of significant (Baker grade 3 or 4) contracture. In this case, the patient underwent SERI implant removal. However, the documentation submitted for review fails to demonstrate the patient had a current infection, seroma or other functional problem that would necessitate implant removal. In addition, the patient stated that she had severe pain, but this is not supported in the medical documentation provided for review. As such, based on the documentation submitted for review, the SERI scaffold removal was not medically necessary in this clinical setting. For the reasons provided, the bilateral breast implant removal performed on 5/7/15 was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 45-year-old male enrollee has requested reimbursement for ipilimumab and nivolumab provided on 6/11/19, 7/02/19, 7/23/19 and 8/13/19. The Health Insurer has denied this request and reported that the medications at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient has a rare metastatic non-clear cell renal cell carcinoma. Among the non-clear cell histologies, renal medullary carcinoma is extremely rare, comprising approximately 2% of all primary renal tumors in young people. Medullary renal carcinoma is a rare and aggressive cell carcinoma variant that almost exclusively arises in patients who are sickle-cell trait positive. Metastatic disease is seen at presentation in 67% to 95% of patients. Chemotherapy remains the focus of treatment for this subtype. Given the lack of benefit of standard therapies and the significant benefit of ipilimumab and nivolumab in patients with non-clear cell renal cell, including some limited data in medullary, the medications at issue were likely to have been superior over any available standard therapy. Therefore, ipilimumab and nivolumab provided on 6/11/19, 7/02/19, 7/23/19 and 8/13/19 were likely to have been more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 45-year-old male enrollee has requested reimbursement for ipilimumab and nivolumab provided on 6/11/19, 7/02/19, 7/23/19 and 8/13/19. The Health Insurer has denied this request and reported that the medications at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient was diagnosed with metastatic medullary renal cell carcinoma. Renal medullary carcinoma is a very rare cancer that arises in the kidney in patients with sickle cell trait or disease.
It comprises less than 0.5% of the total cases of kidney cancer. Its extreme rarity also makes it difficult to judge therapeutic modalities. One cannot expect a randomized clinical trial or even a phase II since there are simply too few patients. There are also no guidelines. There are anecdotal reports of durable responses to certain cytotoxic agents. The patient was started on nivolumab and ipilimumab. According to the National Comprehensive Cancer Network guidelines, for collecting duct or medullary subtypes, partial responses have been observed with cytotoxic chemotherapy Outside of clinical trials, platinum based chemotherapy regimen should be the preferred therapy for renal medullary carcinoma. Based on current guidelines and medical evidence, ipilimumab and nivolumab were not indicated for this patient. They were appropriate in the context of a clinical trial. In sum, ipilimumab and nivolumab provided on 6/11/19, 7/02/19, 7/23/19 and 8/13/19 were not likely to have been more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 45-year-old male enrollee has requested reimbursement for ipilimumab and nivolumab provided on 6/11/19, 7/02/19, 7/23/19 and 8/13/19. The Health Insurer has denied this request and reported that the medications at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the medications at issue in this clinical setting. In patients with widespread metastatic renal cell cancer, this combination of immunotherapy drugs is superior to more standard therapy, and is currently the recommended treatment. The medullary variant is a rare variant, and there is less data concerning this type. Nonetheless, this combination was likely to have been more effective than other treatment alternatives. Thus, ipilimumab and nivolumab provided on 6/11/19, 7/02/19, 7/23/19 and 8/13/19 were likely to have been more beneficial than other available treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 48-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health outpatient treatment, two times per week, from 1/15/19 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that there is no description of the type of therapy. The records indicate that she is seeing a psychiatrist on a regular basis. The clinical progress notes from the psychiatrist do not recommend a specific interval for psychotherapy sessions. There are no other recommendations in the clinical records that specify frequency. Per the records, this patient has a history of bipolar disorder and has had prior hospitalizations as well as suicidal ideation. At her appointment in February 2019, she was having suicidal ideation. Thus, she does need frequent therapy in order to help prevent possible suicide attempts as well as further inpatient acute admissions. The records note emotional dysregulation and symptoms of bipolar disorder. Based on the records, the patient would likely benefit from therapy on a weekly basis. The literature indicates that psychotherapy is effective for the management of symptoms of bipolar disorder. Scott and colleagues noted that efficacy studies demonstrate that adjunctive psychological treatments for individuals with bipolar disorders reduce relapse risk. The literature does not specify the exact frequency of psychotherapy. Typically, the frequency is dictated by the symptom presentation of the patient. In this patients case, weekly outpatient services were and are medically necessary. Weekly therapy is a standard frequency in behavioral health treatment. There is no indication or clinical recommendation for twice weekly therapy. Therefore, mental health outpatient treatment, two times per week, from 1/15/19 forward was not and is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 57-year-old male enrollee has requested reimbursement for CPT 43210 esophagogastroduodenoscopy with transoral incisionless fundoplication performed on 4/23/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that Transoral incisionless fundoplication is an endoscopic procedure performed under general anesthesia to create a full-thickness serosa-to-serosa plication that is 3 to 5 cm in length and 200 to 300 degrees in circumference. In the trial by Trad and colleagues, 63 patients with gastroesophageal reflux disease refractory to proton pump inhibitor (PPI) therapy received transoral incisionless fundoplication versus maximum standard dose PPI therapy. At six months, both regurgitation and extraesophageal symptoms were eliminated in more transoral incisionless fundoplication than PPI patients (62 versus 5%); 90% of transoral incisionless fundoplication patients were off PPIs. After six months, all patients in the PPI (control) group elected to cross over to TIF. At three years, 90 and 88 percent of patients reported elimination of troublesome regurgitation and all atypical symptoms, respectively. At five years, 34 percent were on daily PPI therapy, and the average total gastroesophageal reflux disease health-related quality of life score improved from 22.2 (baseline) to 6.8. In a meta-analysis by Huang and colleagues of five randomized trials and 13 prospective studies, PPI use after transoral incisionless fundoplication increased over time; the satisfaction rate was only 69% at six months. In this case, the patient already underwent laparoscopy for repair of his hiatal hernia. The standard of care would have been to perform a laparoscopic fundoplication in that setting. Instead, a transoral incisionless fundoplication was performed, which has no significant advantage and likely has reduced durability compared to a surgical fundoplication. Therefore, CPT 43210 esophagogastroduodenoscopy with transoral incisionless fundoplication performed on 4/23/21 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The patient is a 61-year-old female with a diagnosis of melanoma measuring 2.65 mm in depth. Her provider submitted a tissue sample for molecular genetic testing with the DecisionDx to determine the risk of metastasis for this tumor. The patient has requested reimbursement for the DecisionDx melanoma assay provided on 6/30/14. The Health Insurer has denied this request indicating that the testing at issue was considered investigational. The DecisionDx melanoma assay tests the tissue genetics of the melanoma to help stratify whether melanoma is high risk for metastasis. The DecisionDx test has shown some accuracy in melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Overall, there is not enough published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx melanoma assay provided on 6/30/14 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

The patient is a 61-year-old female who underwent testing with the DecisionDx melanoma gene testing to assess the metastatic risk of the 2.65 mm Breslow depth melanoma identified on her left ear. The patient has requested reimbursement for the DecisionDx melanoma assay provided on 6/30/14. The Health Insurer has denied this request indicating that the testing at issue was considered investigational. The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such at the DecisionDx Melanoma gene assay should not be used outside of clinical trials as its utility remains to be proven. Moreover, there is a paucity of data demonstrating that results of the DecisionDx assay results in treatment changes that improve health outcomes. Overall, the testing requested is not considered to be standard of care in the evaluation and treatment of melanoma. Accordingly, the DecisionDx melanoma assay provided on 6/30/14 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

The patient is a 61-year-old female with cutaneous melanoma on the left ear. A pathology report revealed non-ulcerating malignant melanoma extending to a depth of 2.65 mm, stage pT3A. The DecisionDx melanoma assay report dated 6/30/14 noted findings of a Class 2 molecular signature associated with a high risk metastatic disease within five years. The patient has requested reimbursement for the DecisionDx melanoma assay provided on 6/30/14. The Health Insurer has denied this request indicating that the testing at issue was considered investigational.  Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. While the majority of clinical stage I patients will be disease-free at five years, some stage I patients will develop advanced disease. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. DecisionDx melanoma assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class 1 consistent with a low risk of metastasis or Class 2 suggestive of a high risk of metastasis. One peer-reviewed publication indicated that there was a statistically significant association of a Class 1 signature by DecisionDx melanoma assay for primary dermal melanoma (PDM), whereas cutaneous metastatic melanoma (CMM) were more frequently Class 2 (Sidiropoulos, et al). The authors concluded that the melanoma prognostic assay may be a useful tool for distinguishing PDM from CMM. According to the results of analysis of this patients melanoma performed with DecisionDx melanoma assay, the tumor was classified as Class 2 with a high risk of near-term (within five years) metastatic disease. Therefore, DecisionDx melanoma signature may be an independent predictor of metastasis risk. Identification of the increased risk of recurrence of melanoma in this patient helped establishing appropriate follow-up plan to improve the outcome in this particular patient. All told, the DecisionDx melanoma assay performed on 6/30/14 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 Upheld

Summary Reviewer 

The parent of a one-year-old male enrollee has requested reimbursement for inpatient services (neonatal care level 3) provided on 8/19/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who had a history of tachypnea. The physician reviewer found that while the patient was not feeding well, with intermittent tachypnea, he was overall hemodynamically stable with no need for assisted ventilation. He was on room air, had improving feeding, and was afebrile. His laboratory tests were concerning, but ultimately cultures were negative. He was intermittently tachypneic, but his chest x-ray was consistent with transient tachypnea of the newborn, and he was slowly improving. It was reasonable and appropriate to pursue evaluation for infection in this case. It was also reasonable to monitor the patient at a level of care higher than the newborn nursery. However, he was not critically ill. He could have been safely and appropriately managed at a lower level of care such as Special Care Nursery, level II. Thus, inpatient services (neonatal care level 3) provided on 8/19/17 was not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.