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

Summary Reviewer 

The patient is a 64-year-old female who was transported by air ambulance from Brazil to Cedar Sinai Hospital (CSH) in Los Angeles, California on 1/18/20. The patient has requested reimbursement for air ambulance transport services provided on 1/18/20. 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, medical necessity criteria must be met. The patientas condition must be such any form of transportation other than ambulance would be medically contraindicated. Additionally, and the patientas  condition is such that time needed to transport by ground poses a threat to the patientas survival, and there is a medical condition that is life-threatening. Such conditions include, but are not limited to, intracranial bleeding, cardiogenic shock, major burns, conditions requiring hyperbaric oxygen, multiple severe injuries, transplants, limb-threatening trauma, or acute myocardial infarction requiring intervention, such as percutaneous transluminal coronary angioplasty. When transporting from one facility to another, the above criteria must be met and the first hospital must not have the required services and facilities to treat the patient. Further, when transferring from one hospital to another, the patient must be transported to the nearest hospital with appropriate facilities for treatment. This patient asserts that the facility she was admitted to in Brazil was not capable of providing appropriate care. Review of the available records indicates otherwise. The patient also states she required admission to a rehabilitation unit and there are no such facilities in Brazil. If such were the case, then transport would have needed to be to the closest facility capable of providing that care. Records do document that the patientas family had requested she be transferred to CSH in Los Angeles, California, to be closer to home and family. Therefore, air ambulance transport services provided on 1/18/20 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 64-year-old male enrollee has requested authorization and coverage for functional electrical stimulation cycle ergometer. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees tetraplegia. The physician reviewer found that the patient has a spinal cord injury that results in reduced mobility and reduced ability to engage in exercise. Functional electrical stimulation cycling has been developed as a means to stimulate muscle activity in paralyzed limbs to reproduce physiological effects of exercise. The literature has explored the effects of functional electrical stimulation cycling to determine if this artificial form of exercise has clinical benefit. The net weight of evidence has been positive, showing that functional electrical stimulation cycling promotes improved health status in people with spinal cord injury. There is sufficient support for the requested device in this clinical setting. Thus, the requested functional electrical stimulation cycle ergometer is medically necessary in this patients case. Therefore, the requested device is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 51-year-old female enrollee has requested authorization and coverage for Vemlidy. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B virus. The physician reviewer found that according to the American Association or the Study of Liver Disease (AASLD) guidelines for treatment of hepatitis B, tenofovir is the first-line recommended therapy for the treatment of hepatitis B (Terrault, et al). Per AASLD guidelines, the goal of therapy is long term viral suppression, unless there is clear seroconversion, when applicable, and long-term undetectable viral DNA. In addition, the Vemlidy formulation of tenofovir is effective for hepatitis B and associated with fewer adverse effects, including osteopenia compared to Viread (Grant, et al). For these reasons, Vemlidy is supported as medically necessary for the treatment of the patients hepatitis B infection. 
For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1
A 35-year-old female enrollee has requested reimbursement for the three-dimensional (3D) mammogram provided on 10/31/16. The Health Insurer has denied this request indicating that the service at issue is considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found that the 3D mammogram provided on 10/31/16 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 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 documentation submitted for review and medical literature cited above, 3D mammogram 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 service 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 35-year-old female enrollee has requested reimbursement for the three-dimensional (3D) mammogram provided on 10/31/16. The Health Insurer has denied this request indicating that the service at issue is considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found that 3D mammograms, also known as tomosynthesis was approved for clinical use by the U.S. Food and Drug Administration in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of mammography the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantage it brings providers interpreting mammograms especially in women with dense tissue such as the patient under review. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in overall diagnostic accuracy compared to two-dimensional mammography.  In this case, the palpable abnormality was better assessed using tomosynthesis in this patient with a strong family history and dense tissue. All told, the 3D mammogram provided on 10/31/16 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 service 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 35-year-old female enrollee has requested reimbursement for the three-dimensional (3D) mammogram provided on 10/31/16. The Health Insurer has denied this request indicating that the service at issue is considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found that in this case, the 3D mammogram was clinically indicated for this patient. The patients breasts are described as extremely dense. It is specifically those patients who have dense breasts that can benefit most from 3D mammogram. The ability to separate out the overlapping structures better enables the possibility of demonstrating an otherwise occult tumor. In addition, the patient presented with a palpable lump. Once a lump is palpated, it is imperative to determine whether a mass is present. For the reasons provided, the 3D mammogram provided on 10/31/16 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 service 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 16-year-old male enrollee has requested reimbursement for mental health outpatient services provided from 11/25/15 through 5/12/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). The physician reviewer found that reviewing therapy progress notes including those from 11/25/15, 12/17/15 and 3/17/16 it was consistently noted that the patient had restlessness, depression, but there was no documentation of any evidence that would warrant extended outpatient sessions. There was no indication that the patient was in crisis or decompensating, or that he required specialized services that would require extended sessions. Overall, the records provided for review suggest this patient could have been reasonably and adequately treated with less intrusive, less invasive level of care, such as regular outpatient therapy sessions. Accordingly, the mental health outpatient services provided from 11/25/15 through 5/12/16 were not medically necessary for treatment of this patients medical condition. Based on the records provided, 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 Overturned

Summary Reviewer 1

The patient is a 44-year-old female who has a personal history of several malignancies including bilateral invasive lobular breast cancer at age 42, non-Hodgkins lymphoma in 1997, thyroid cancer in 1998, and a mucoepidermoid carcinoma of the trachea in 2009. Her family history is significant for a sister with thyroid cancer at age 34.  The records noted a sister was diagnosed with non-Hodgkins lymphoma at 42. Her paternal grandmother was diagnosed with uterine cancer in her 60s, her mother was diagnosed with thyroid cancer at 66, two maternal cousins were diagnosed with thyroid cancer, and a maternal uncle was diagnosed with leukemia at age 18. The patient has requested reimbursement for gene testing performed on 11/28/16.  The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. This patient has an extensive personal history of cancer, including breast cancer before the age of 50 that was bilateral. Her family history is also suggestive of a familial genetic predisposition to thyroid cancer on the maternal side. More than one gene could explain the patients genetic risk of cancer. If a gene is identified, this could help guide prevention and treatment strategies.  This patient meets criteria for BRCA1 and BRCA2 testing. The largest studies reporting on the outcomes of multigene testing indicate that among women tested in clinical settings, about 5 to 10 percent have a BRCA1 or BRCA2 mutation, and about 4 to 7 percent have a harmful mutation in another gene associated with high to moderate risks of breast and/or ovarian cancer, or a mutation in a newer gene that may also be associated with increased risks for these cancers. She also has a significant family history, and testing positive for a mutation would guide additional therapy, such as mastectomy or oophorectomy as well as how to manage her screening for another breast cancer or other cancer. The medical evidence supports the services at issue in this clinical setting.  All told, gene testing performed on 11/28/16 was likely to have been more effective than 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

The patient is a 44-year-old female who has had bilateral breast cancer. In addition, she has also had non-Hodgkins lymphoma and mucoepidermoid cancer. She has a strong family history of cancer, with a sister with lymphoma, sister with thyroid cancer and a paternal grandmother with uterine cancer. There are other members of the family with thyroid cancer. In November 2016, her blood was submitted for the MyRisk genetic susceptibility panel.  The patient has requested reimbursement for gene testing performed on 11/28/16.  The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. BRCA testing guidelines recommend BRCA testing for this patient as she was diagnosed with breast cancer at the age of 42.  However, at issue is the MyRisk panel, which is a 25 gene panel that includes BRCA within it, but also a variety of other suspected risk genes. Although many of these gene mutations are of real interest and are being actively studied, for the most part they have as yet not been found to be significant or predictive enough to be the basis for clinical decisions by the carriers or their family members. Such panel testing is not included in the guidelines from major organizations. Thus, gene testing performed on 11/28/16 was not likely to have been more effective 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 Overturned

Summary Reviewer 3

The patient is a 44-year-old female with a history multiple malignancies, including breast cancer.  Per the records, she had an abnormal uterine ultrasound. She has a significant family history, including a sister with non-Hodgkins lymphoma, a sister with thyroid cancer, two cousins with thyroid cancer, and a mother with thyroid cancer. The history was suggestive of a familial predisposition of cancer which prompted testing using the MyRisk panel. The patient has requested reimbursement for gene testing performed on 11/28/16.  The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  This patients family history is suggestive of a breast/ovarian cancer syndrome. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gallbladder, bile duct, prostate, pancreatic, and gastric cancers. In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. There are guidelines in place that evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families. The most common extracolonic cancer in Lynch syndrome is endometrial cancer followed, in no particular order, by ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral. In this patients case, the MyRisk panel was appropriate since the current clinical situation may be caused by several potential cancer-causing genes. Thus, genetic testing performed on 11/28/16 was 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 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

The parent of a one-year-old male enrollee has requested authorization and coverage for Olumiant
1 mg tablet. The Health Insurer has denied this request and reported that the requested medication
is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting. Aicardi-
GoutiA res Syndrome (AGS) is recognized as a Type 1 interferonopathy, which leads to
autoimmune-mediated inflammation. Uncontrolled autoimmune inflammation results in a wide
range of disease manifestations with the central nervous system (CNS), in particular, being
affected. This is an important point to make, because any conventional FDA-approved medicine
that treats CNS disease, including all available antiepileptic medications, does not address the
underlying disease processes in AGS. In this patientas case, Olumiant therapy offers the chance
for a marked reduction in AGS-associated morbidity. Therefore, Olumiant 1 mg tablet is likely to
be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

The parent of a one-year-old male enrollee has requested authorization and coverage for Olumiant
1 mg tablet. The Health Insurer has denied this request and reported that the requested medication
is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that AGS is a rare monogenic interferonopathy characterized by variable neurologic dysfunction,
ranging from mild spastic paraparesis to quadriparesis and severe cognitive disability. Mutations
on one of six genes involved in nucleic acid repair have been implicated in the majority of cases,
with additional rare ade novoa autosomal dominant cases. Excessive interferon production results
in systemic inflammation and extensive end organ injury. Patients typically present with altered
mental status, including lethargy and irritability, feeding intolerance, and neurologic
abnormalities, such as loss of gross motor skills, seizures, or spasticity. Some patients may also
exhibit signs of systemic autoinflammation, such as fevers and skin involvement. There is evidence
of basal ganglia calcification, chronic cerebrospinal fluid (CSF) lymphocytosis, and elevated CSF
interferon type I. There are similarities and symptom overlap with systemic lupus erythematosus.
Overall, there is currently significant morbidity and high rate of mortality associated with this
syndrome. As a disorder of inappropriate immune activation, AGS has prompted interest in
immune-mediation therapies, including Janus kinase (JAK) inhibitors, reverse transcriptase
inhibitors, anti-IFN-alpha antibodies, anti-interleukin antibodies, antimalarial drugs, and other
cGAS inhibitors. Olumiant (baricitinib) is an oral JAK1/2 inhibitor that has been approved for
treatment of rheumatoid arthritis and has been used in case studies on patients with AGS.
Individual patients with AGS experienced decreased skin manifestations as well as improved
neurologic function following treatment with baricitinib.
This medication has not been approved by the U.S. Food and Drug Administration (FDA) in this
population, and the majority of articles cite the need for ongoing clinical studies, which are
particularly challenging given the heterogeneous nature of this disease. However, the FDA has
listed AGS as one of the conditions for which baricitinib can be used on a compassionate basis.
This medication is the only treatment available and is more likely to be beneficial than standard
therapy (symptomatic treatment only). Therefore, Olumiant 1 mg tablet is likely to be more
beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

The parent of a one-year-old male enrollee has requested authorization and coverage for Olumiant
1 mg tablet. The Health Insurer has denied this request and reported that the requested medication
is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that AGS is a rare genetic neurological disease with onset in infancy. This patient has a mutation in the
SAMHD1 gene, one of the genes that has been noted to be associated with AGS. Meesilpavikkai
and colleagues described the successful treatment of chilblains in AGS patients with a SAMHD1
mutation and consequent uparegulation of type I interferon activity. JAK/STAT activation is
present in various autoimmune diseases, and treatment with specific JAK inhibitors in immunemediated
diseases has been increasingly reported. The oral JAK1/2 inhibitor baricitinib (Olumiant)
has been approved for the treatment of active rheumatoid arthritis. Vanderver and colleagues
recently reported that treatment of patients with AGS using baricitinib resulted in decreased skin
manifestations and improved neurological function. An ongoing phase II clinical trial of baricitinib
in AGS is on hold due to the coronavirus pandemic. There is no standard therapy available for
AGS. The syndrome is progressive. There appears to be a narrow window of opportunity for
effective intervention. The requested medication may arrest the progression of ongoing
inflammation and neurological deterioration. Therefore, Olumiant 1 mg tablet is likely to be more
beneficial than other available standard therapy.