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

Summary Reviewer 


A 22-year-old female enrollee has requested reimbursement for residential mental health treatment services provided from 9/16/15 through 10/16/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the services in dispute were reasonably expected to improve the patients condition while appropriate care could not have been effectively delivered in a less restrictive setting at the time. Developmentally, the patient had an abysmal sense of self and had failed to achieve the developmental milestone of identity formation. As such, she endured rather chaotic role diffusion manifest by self-defeating cognitive schemas and cyclical maladaptive patterns of behavior. Complicating this underlying foundation was the presence of anxiety and substance use disorders that generated impairment across multiple domains including the areas of occupational, academic, social and family functioning. The patient had failed less restrictive interventions during the episode of illness and was evaluated for suicidality in the acute setting just prior to admission. She was unemployed and not in school. She had poor insight and strained family relations. She did not have a support network conducive to recovery in the outpatient setting.  The patient required treatment from behavioral health specialty providers. The patient engaged in active treatment, including dialectical behavior therapy and pharmacotherapy, in structured and supervised setting that forced her to safely confront her distorted cognitions and maladaptive coping skills. Further, both the setting and services were safe, appropriate and consistent with good medical practice, and the duration of care was well within typical community standards. Finally, the disputed service laid the foundation for a successful transition to a community-based after-care program to continue the recovery process. Thus, the services at issue were medically necessary for treatment of the patients medical condition. 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 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  There is a lack of prospective controlled data to support random measurement of Remicade/Remicade antibody levels.  The concept of targeted drug level monitoring is supported for several classes of drugs.  However, evidence is lacking for biologic agents in the treatment of this patients condition.  There are multiple variables which drug level monitoring does not consider, thus making this line of testing suboptimal.  For example, the optimal trough level of Remicade remains unknown and likely varies from individual to individual based on unique pharmacokinetics.  Additionally, tissue levels of drug also play an important role.  Therefore, Anser IFX testing performed on 8/17/15 was not likely to have been superior over other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


A 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found the current medical evidence has not established the superior efficacy of the services at issue.  Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment.  The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  However, while there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  All told, Anser IFX testing performed on 8/17/15 was not likely to be more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found the management of ulcerative colitis using Anser IFX testing has not been standardized, and standardized recommendations for management based on test results (change to a different medication versus increase in dose) have not been formed. The use of Anser IFX testing to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in high-quality controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold drug levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, there was a lack of standard guidelines defining a therapeutic strategy at the time of testing.  Per the clinical literature, Anser IFX testing performed on 8/17/15 was not likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 73-year-old male with a history of severe aortic stenosis. The patient was referred for transcatheter aortic valve replacement treatment.  The U.S. Food and Drug Administration has expanded the indications for transcatheter aortic valve replacement to include patients at lower risk for aortic valve surgery who meet clinical criteria for aortic valve replacement. In this case, transcatheter aortic valve replacement plus a two day hospital stay is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 48-year-old male enrollee has requested reimbursement for magnetic resonance imaging (MRI) performed on 5/11/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  As stated by Roudsari and Jarvik, in the setting of low back pain (LBP), all of the guidelines emphasize the importance of a focused history and thorough physical examination before any imaging is ordered.  In addition, all agree that for patients with acute LBP and without any risk factor for serious spine abnormalities, imaging within the initial 48 weeks should not be performed.  Per Chou and colleagues, clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy).  In this patients case, the one-day history of low back pain, regardless of whether the patient has a radiculopathy, does not warrant an immediate MRI scan.  All told, the requested MRI performed on 5/11/15 was not medically indicated 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 44-year-old female enrollee has requested reimbursement for BRCA testing performed on 3/17/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees risk of cancer.  The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Screening patients with no personal history of breast cancer is indicated when an individual has a family history of one or more of the following: a blood relative with a known mutation in a gene that increases cancer risk, a blood relative with two or more primary breast cancers, two or more relatives with breast cancer on the same side of the family with at least one diagnosed before age 50, a blood relative with ovarian cancer, a close blood relative with breast cancer before age 45, a blood relative with male breast cancer or anyone of Ashkenazi Jewish ancestry with breast, ovarian, or pancreatic cancer at any age. The patient does not meet criteria for the BRCA testing performed on 3/17/16. 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 44-year-old female enrollee has requested reimbursement for BRCA testing performed on 3/17/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees risk of cancer.  The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. This patient does not meet established guidelines for testing for BRCA mutations (Robson, et al). She does not have a personal history of cancer, is not identified as being from a high risk ethnic group such as Ashkenazi Jewish and has identified one second or later degree relatives on both sides of the family that are over the age of 50. A third relative is mentioned but no information is provided. In this clinical setting, pre-test counseling would likely be more beneficial than BRCA testing with a genetic risk assessment based on personal and family history. Therefore, the BRCA testing performed on 3/17/16 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 44-year-old female enrollee has requested reimbursement for BRCA testing performed on 3/17/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees risk of cancer.  The physician reviewer found that most patients for whom genetic testing is ordered have an affected first-degree relative. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers (Brose, et al; Thompson, et al). BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers (Liede, et al; Tai, et al). In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. In this case, the patients family history is not suggestive of a heritable risk. The patient should proceed to standard mammography and physical exam. In sum, there is a lack of clinical documentation supporting the BRCA testing provided on 3/17/16 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 not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 66-year-old female enrollee has requested authorization and coverage for ablation of varicose veins, right and left accessory ablation.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that in this case, the patient has already undergone great saphenous vein removal.  The reflux from the incompetent saphenofemoral junctions is now going down the accessory saphenous veins.  These veins are very large, and have free reflux.  They are essentially acting as refluxing greater saphenous veins. In the situation where these veins can be ablated, this treatment is standard of care.  All told, the requested ablation of varicose veins, right and left accessory ablation is likely to be of greater benefit than other treatment options.  Based upon the information set forth above, the requested services are 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
A 66-year-old female enrollee has requested authorization and coverage for ablation of varicose veins, right and left accessory ablation.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  Patients with anterior accessory saphenous vein reflux and patients with the great saphenous vein reflux demonstrate similar disease-specific features.  Following great saphenous veins ablation, persistent non-refluxing branches do not appear to have an adverse impact on clinical outcome two years after successful ablation of the great saphenous vein.  Although there is limited clinical data to recommend ablation of the non-axial veins, the published data suggest it is effective in selected patients.  There is evidence to support sclerotherapy in the treatment of accessory recurrent varicose veins following ablation.  Thus, ablation of varicose veins, right and left accessory ablation is likely to be more effective than other treatment options.  Based upon the information set forth above, the requested services are 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 66-year-old female enrollee has requested authorization and coverage for ablation of varicose veins, right and left accessory ablation.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that while endovenous ablation of the greater saphenous vein has been extensively evaluated in the treatment of varicose veins, little is known about the efficacy in the treatment of accessory saphenous veins.  Furthermore, patterns of recurrence of varicose veins after greater saphenous vein treatment is usually new reflux in the accessory saphenous vein and there is little evidence available to guide optimal therapy, in contrast to greater saphenous vein interventions.  Therefore, given the absence of evidence for the efficacy of endovenous ablation of accessory saphenous veins after surgical therapy of greater saphenous vein incompetence, the superior effectiveness of the requested services has not been established.  Based upon the information set forth above, the requested services are 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 43-year-old male enrollee has requested reimbursement for Anser IFX testing performed on 8/09/15.  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.  This patient has had interrupted therapy with Remicade.  He was failing all therapy and may require extensive surgery. Remicade was restarted, but he appeared to be having an immune response to therapy.  It was important to determine if there were antibodies as their presence will make further therapy futile.  In sum, Anser IFX testing performed on 8/09/15 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 43-year-old male enrollee has requested reimbursement for Anser IFX testing performed on 8/09/15.  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 some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment.  The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  However, there are few well-controlled clinical trials to confirm that use of the Anser IFX testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  In sum, the superior efficacy of Anser IFX testing performed on 8/09/15 has not been established.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 43-year-old male enrollee has requested reimbursement for Anser IFX testing performed on 8/09/15.  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 medical evidence supports the services at issue for the management of this patient with Crohns disease.  The documentation noted that he was being treated with Remicade infusion and reported back pain and abdominal pain.  The purpose of measuring the drug level and antibodies to the drug is to optimize therapy to achieve therapeutic response and induce remission in patients with active Crohns disease, and to also to help the treating provider to make a decision to switch to a different biologic in the event the patient has developed an antibodies to the drug.  Thus, Anser IFX testing performed on 8/09/15 was likely to have been more beneficial than other modalities for 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 Overturned

Summary Reviewer 

The patient is a 66-year-old male with a history of chronic neck pain associated with severe central
spinal stenosis at C5-6 and moderately severe spinal stenosis at C6-7, cord compression, and
myelopathy. The clinical examination corroborates the MRI findings with severe pain, disability,
and spinal cord compression at C5-6. The physician reviewer found that based upon the clinical findings corroborating the imaging findings and severe two-level
degenerative disc disease with myelopathy, there is a need for urgent decompression. Per the
current medical literature, a two-level total disc replacement at C5-6 and C6-7 is indicated. In the
study referenced here, 599 patients were followed for seven years. At seven years, the two-level
total disc replacement was found to be superior to anterior cervical discectomy and fusion. There
were lower rates of revision surgery and lower rates of adjacent level disc disease. The surgery
was very effective in relieving pain. Complication rate was very low. Overall, greater than 95% of
patients were AaAvery satisfiedAaA at seven years. There is sufficient support for the requested services
in this clinical setting. Therefore, the requested cervical disc arthroplasty is medically necessary
for the treatment of this patient.