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

Summary Reviewer 3

A 66-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 8/10/17.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees lung adenocarcinoma. The physician reviewer found that the therapy of advanced non-small cell lung cancer has been revolutionized by the finding of epidermal growth factor receptor (EGFR) mutations in certain adenocarcinomas. The mutations are more common in those who have never smoked.  Even if stage IV disease is present, therapy targeted to EGFR with erlotinib results in prolonged survival when compared with standard chemotherapy regimens. The mutational landscape of non-small cell lung cancer has significantly expanded in the past two to three years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. Patients on targeted therapy may develop resistance to erlotinib, and this may be appreciated at the genetic level by recognition of new mutations or amplifications in parallel signal transduction pathways. 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 comparing the use of targeted agents with conventional chemotherapy approaches. The study involved 86 patients, and the progression-free survival on regimen selected by molecular profiling was compared to the progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has significant results for patients with stage IV tumors. In this patients case, the results from molecular profiling may offer a rational selection of the next regimen. Thus, Guardant360 testing performed on 8/10/17 was likely to have been superior over 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 33-year-old female enrollee has requested reimbursement for Fragile X mental retardation 1 laboratory testing (81243) performed on 8/09/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that Prenatal screening for fragile X syndrome is not currently a part of universal screening in terms of genetic testing for routine prenatal care. The testing is performed to identify individuals at risk for conceiving a child with clinical manifestations of the disorder. Per the American College of Obstetricians and Gynecologists (ACOG), screening for fragile X syndrome is offered in women after a careful assessment of the family history is performed to identify individuals with sufficient likelihood of premutation or full mutation carrier status to warrant such screening.  The following is used as criteria for such screening: individuals seeking reproductive counseling who have a family history of fragile X syndrome (confirmed premutation or full mutation of FMR1 gene) or intellectual disability of undetermined etiology; individuals of either sex with intellectual disability or developmental delay of undetermined etiology, or autism; young women with elevated levels of follicle-stimulating hormone, especially with a family history of premature ovarian insufficiency (menopause before age 40), fragile X syndrome, or a relative of either sex with intellectual disability of undetermined etiology; and individuals with late-onset intention tremor or ataxia (usually after age 50), especially with a history of infertility, family history of movement disorders, fragile X, or intellectual disability of undetermined etiology. Universal screening is not offered, in part, due to the difficulty in predicting phenotype in offspring of low-risk women (women with a negative personal and family history) with a premutation. Given the clinical documentation, there is no clear support that the patient is at high risk to warrant screening.  Therefore, fragile X mental retardation 1 laboratory testing provided on 8/09/19 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 64-year-old female enrollee has requested reimbursement for CT of the thorax. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Nontuberculous mycobacterial pulmonary infection can have various radiologic manifestations. These imaging findings include tree-in-bud opacities, bronchiectasis and ground glass opacities, most commonly in the right middle lobe and lingula. These findings are often not visualized on conventional chest radiographs and are best detected on chest CT. In this case, the patients initial abnormalities were not seen on prior radiographs but were subsequently seen on chest CT. Since the patient had a recurrence of symptoms status post antibiotic treatment, the best way to visualize this recurrence would be on chest CT, as her initial findings were below the detection of radiographs. The results of the CT scan affected the patients clinical management, prompting bronchoalveolar lavage as well as additional treatment. Therefore, CT of the thorax performed on 11/09/18 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 60-year-old male enrollee has requested reimbursement for repair of anorectal fistula provided on 10/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees anal fistula. The physician reviewer found that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Anorectal fistula are difficult, painful and not always amenable to definitive treatment. Historical treatment that involved unroofing often led to incontinence as the sphincters were divided. Setons, which are sutures placed through the tract, allow fibrosis that may reduce complications of subsequent surgery. The anal fistula plug does hold some potential advantages over mucosal advancement flap, especially in complex fistula with multiple openings. The anal fistula plug is easy to place, does not require a flap to heal in a contaminated environment, and may be associated with less pain. In addition, healing rates are equivalent in large, heterogeneous studies. However, in this case, the documentation submitted for review does not describe the location of the fistula or description of previous repair attempts. In sum, there is limited documentation supporting the anorectal fistula provided on 10/23/15 as 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 services at issue were 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 60-year-old male enrollee has requested reimbursement for repair of anorectal fistula provided on 10/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees anal fistula. The physician reviewer found that the repair of anorectal fistula provided on 10/23/15 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue. The study by Stamos and colleagues study assessed outcomes after implantation of a synthetic bioabsorbable anal fistula plug. The authors concluded Implantation of a synthetic bioabsorbable fistula plug is a reasonably efficacious treatment for complex transsphincteric anal fistulas, especially given the simplicity and low morbidity of the procedure. The use of AFP is the best option to avoid significant anal sphincter muscle damage, and resultant fecal incontinence in this clinical setting. Therefore, AFP was the superior surgical approach for treatment of the fistula without causing significant anal sphincter damage and fecal incontinence. Accordingly, the services at issue were 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 services at issue were 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 60-year-old male enrollee has requested reimbursement for repair of anorectal fistula provided on 10/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees anal fistula.  The physician reviewer found that the American Society of Colon and Rectal Surgeons (ASCRS) has published practice parameters for the management of perianal abscess and fistula-in-ano (Steele, et al). The treatment recommendations for complex fistulas include seton, fistulotomy, fibrin glue, plug, endorectal advancement flap, and ligation of intersphincteric fistula tract. Placement of a seton with or without fistulotomy has a strong recommendation based on moderate evidence. The use of the Gore Bio-A fistula plug has been recently evaluated in recent studies. In the prospective study by Herold and colleagues, 60 patients with transsphincteric fistulas underwent plug placement and the healing rate at one year was 52%. Most importantly, there was no effect on incontinence which can be a side effect of other procedures performed for management of anal fistula such as cutting seton, fistulotomy, or endorectal advancement flap. In the study by Stamos and colleagues, 93 patients with transsphincteric fistulas were treated at 11 colon and rectal centers. The healing rates at six and 12 months were 41% and 49%, respectively. The authors concluded that implantation of a fistula plug is reasonably efficacious treatment for anal fistula, especially given its simplicity and low morbidity. Given that the support in the peer-reviewed literature and ASCRS practice parameters, the anorectal fistula provided on 10/23/15 was 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 services at issue were 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 1


A 62-year-old male enrollee has requested reimbursement for laboratory testing (Fibrotest-Actitest) performed on 8/14/15.  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 there is sufficient support for the services at issue in this clinical setting.  Fibrotest and Actitest permit the noninvasive evaluation of patients with hepatitis C or hepatitis B for the presence of liver fibrosis and liver inflammation, respectively.  Fibrotest and Actitest scores, on a scale of 0.0 to 1.0, are assigned a Metavir scale indicating the level of fibrosis or inflammation present.  Several prospective studies have confirmed the overall accuracy of the Fibrotest in discriminating advanced from non-advanced fibrosis.  All told, laboratory testing performed on 8/14/15 was likely to have been superior over other methods of evaluation.  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 62-year-old male enrollee has requested reimbursement for laboratory testing (Fibrotest-Actitest) performed on 8/14/15.  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 there is sufficient support for the services at issue in this clinical setting.  It is standard of care in contemporary gastroenterology to use when possible noninvasive testing as a measure of hepatic fibrosis.  Elastography is one such noninvasive technique whereby ultrasound imaging provides objective data to evaluate tissue elasticity or stiffness by measuring tissue displacement.  When liver biopsy is undesired, FibroScan demonstrates greater accuracy, sensitivity, and specificity for predicting and discriminating minimal or no fibrosis from extensive fibrosis.  FibroSure is more widely available than FibroScan, and represents a well-recognized community-standard approach to noninvasive assessment of hepatic fibrosis.  In this patients case, the current medical evidence supports the services at issue.  Thus, laboratory testing (Fibrotest-Actitest) performed on 8/14/15 was likely to have been more efficacious than other methods of evaluation.  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 62-year-old male enrollee has requested reimbursement for laboratory testing (Fibrotest-Actitest) performed on 8/14/15.  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 the Fibrotest-Actitest is a serum blood test to characterize fibrosis and determine whether cirrhosis is present.  With liver biopsy as the gold standard, Fibrotest has been found to perform well enough to be an effective alternative to biopsy in patients with chronic hepatitis B.  Accordingly, published studies have concluded that Fibrotest-Actitest is an effective alternative to liver biopsy.  In this patient with established cirrhosis, and prior liver biopsy, Fibrotest-Actitest provided a noninvasive alternative to repeating liver biopsy.  For these reasons, laboratory testing performed on 8/14/15 was likely to have been of greater benefit than other methods of evaluation.  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 the breast tomosynthesis provided on 2/1/16.  The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it brings to radiologists interpreting mammograms especially in patients with extremely or heterogeneously dense tissue such as the patient in this case. Tomosynthesis allows radiologists to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of tomosynthesis to the usual two-dimensional imaging protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. 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 64-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 2/1/16.  The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the breast tomosynthesis performed on 2/1/16 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Ciatto and colleagues investigated the effect of integrated two-dimensional (2D) and three-dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls. Based on the medical literature cited above, the use of breast tomosynthesis 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 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 64-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 2/1/16.  The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patients breasts were described as heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, the breast tomosynthesis performed on 2/1/16 were 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 services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 50-year-old male enrollee has requested reimbursement for BCR/ABL gene rearrangement and the Tempus XT Gene Panel Testing performed on 12/17/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient has a grade I meningioma. Magnetic resonance imaging (MRI) showed a question of slow growth versus tumor progression. There is no rationale for molecular profiling or BCR-ABL testing in this patient. Molecular profiling is used to determine treatment options in certain malignancies, but not grade I meningiomas. BCR-ABL is used in the detection and monitoring of chronic myelogenous leukemia, acute myeloid leukemia and acute lymphoblastic leukemia. In rare cases, BCR-ABL1 has been described in essential thrombocytosis, myelodysplastic syndrome, multiple myeloma (plasma cell myeloma), and malignant lymphoma. Therefore, BCR-ABL gene rearrangement and the Tempus XT Gene Panel Testing performed on 12/17/18 were not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 50-year-old male enrollee has requested reimbursement for BCR/ABL gene rearrangement and the Tempus XT Gene Panel Testing performed on 12/17/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that testing for BCR-ABL is a gene mutation particularly prominent in chronic myelogenous leukemia, for which there is a specific targeted treatment (imatinib). There has been interest in using this drug in meningioma, although the results have been equivocal at best. There is a lack of convincing data that imatinib, regardless of mutational status, is clinically beneficial in meningioma. The Tempus XT gene panel is one of many multigene panels theoretically designed to identify a gene target for therapy. Thus far, the use of such panels appears to be rarely beneficial overall. In sum, BCR-ABL gene rearrangement and the Tempus XT Gene Panel Testing performed on 12/17/18 were not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 50-year-old male enrollee has requested reimbursement for BCR/ABL gene rearrangement and the Tempus XT Gene Panel Testing performed on 12/17/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that a patient may exhibit resistance to therapy, and mutational analysis may be needed. This is particularly important for those that have progressed on standard regimens. The medical evidence supports clinical trials for such patients and considers such referrals standard care. Von Hoff and colleagues performed a study of 86 patients. The progression-free survival on the regimen selected by molecular profiling was compared to progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. The Tempus XT gene panel is a mutational analysis of tissue which includes IDH1/2, BCR-ABL1, BRAF, CEBPA and microsatellite instability test. This patient had mutational analysis performed on his meningioma, and some targeted regimens were recommended based on this tumor mutational analysis. The results from molecular profiling may offer a rational selection of the next regimen. Thus, BCR-ABL gene rearrangement and the Tempus XT Gene Panel Testing performed on 12/17/18 were likely to have been more beneficial than other methods of evaluating this patient.