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

Summary Reviewer 2

A 63-year-old female enrollee has requested reimbursement for ExoSym kinetic orthosis for right knee provided on 9/12/16. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees right knee pain. The physician reviewer found that there is a paucity of high level clinical trials supporting the use of ExoSym kinetic orthosis in treatment of grade 4 arthritic knees. The patients records document that she has exhausted all measures of conservative treatment. In this clinical setting, knee replacement surgery would be indicated. ExoSym kinetic orthosis is not likely to be more beneficial than available standard treatment including total knee arthroplasty. Thus, the ExoSym kinetic orthosis for right knee provided on 9/12/16 was not 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 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 Upheld

Summary Reviewer 3

A 63-year-old female enrollee has requested reimbursement for ExoSym kinetic orthosis for right knee provided on 9/12/16. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees right knee pain. The physician reviewer found that this patient has chronic subjective instability and knee pain following a remote ACL reconstruction of the right knee. There are some associated degenerative changes in the lateral compartment. A posterolateral reconstruction was not substantially beneficial. In this clinical setting, a custom orthosis equipped with dynamic tensioning system can lower the strain on the meniscus, limits tibial rotation, and help protect the ACL graft, as well as reduce pain and subjective instability. Accordingly, the ExoSym kinetic orthosis for right knee provided on 9/12/16 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 device at issue was 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 Upheld

Summary Reviewer 1


A 28-year-old female enrollee has requested reimbursement for the Anser ADA testing performed on 12/1/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the Anser ADA testing performed on 12/1/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based on the documentation submitted for review, there is a lack of clinical indication for the testing at issue. The patient was not experiencing failure of the anti-tumor necrosis factor agent as the patient was reported to be doing well with Humira. Given the above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


A 28-year-old female enrollee has requested reimbursement for the Anser ADA testing performed on 12/1/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the Anser ADA testing performed on 12/1/15 is not supported by the documentation submitted for review. In this case, the patients Crohns was responsive to Humira, but she developed a rash of uncertain origin for which the Prometheus Anser assay was ordered. It has not yet been established in the peer-reviewed literature 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. Generally, diminished or suboptimal response to adalimumab can be managed by shortening the interval between doses, increasing the dose, switching to a different anti-TNF agent or switching to a non-anti-tumor necrosis factor agent based on clinical observation in lieu of Anser testing. For the reasons provided, the Anser ADA testing performed on 12/1/15 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 28-year-old female enrollee has requested reimbursement for the Anser ADA testing performed on 12/1/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the use of Anser ADA testing has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. The effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with adalimumab may experience drug reactions or loss of response, but the appropriate method for determination of the cause for these is not clear. The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature (Karmiris, et al; Imaeda, et al). The study by Karmiris and colleagues found no direct relationship between trough serum adalimumab concentration or anti-adalimumab antibody and short-term treatment efficacy. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. In sum, there is a lack of medical literature supporting Anser ADA as 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 39-year-old male enrollee has requested authorization and coverage for Xeljanz. 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 this patientas condition is not controlled by the standard steroid injections treatment or methotrexate. In the past, his hair loss had progressed to the totalis pattern. For challenging patterns of alopecia areata, oral tofacitinib is an excellent choice for the next step on the treatment ladder. There is a significant volume of peer-reviewed literature demonstrating efficacy. In this
patientas case, Xeljanz is likely to be more effective than any other standard therapy. Other untried, non-standard therapeutic options are systemic and fraught with cumulative toxicities and other dangerous side effects. Tofacitinib is a well-known and commonly used therapeutic for alopecia areata. Therefore, Xeljanz is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 39-year-old male enrollee has requested authorization and coverage for Xeljanz. 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 this patient has been treated with intralesional steroids, topical steroids, as well as systemic steroids. His area of involvement has been as severe as alopecia totalis, which affects scalp, eyebrows, and eyelashes. He received treatment with Xeljanz in the past and did well. It was the best at keeping him in remission. As this patient did have a documented improvement in the past with Xeljanz, it is reasonable to continue with that treatment plan. Therefore, Xeljanz is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 39-year-old male enrollee has requested authorization and coverage for Xeljanz. 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 available treatment options for alopecia areata are quite limited. This is especially true for diffuse/multifocal involvement, where standard therapies such as topical steroids, intralesional Kenalog, contact immunotherapy and conventional immunosuppressants are more often than not less than satisfactory and associated with side effects. Although there is no significant data yet from randomized clinical trials (which are currently underway), there is substantial clinical evidence to support the use of oral Janus kinase inhibitors such as tofacitinib for alopecia areata. In one open label pilot study, eight of 12 patients demonstrated approximately 50% hair regrowth as measured by Severity in Alopecia Tool (SALT) scoring. There have been minimal adverse effects reported to date. Moreover, these results are better than what has been reported for contact immunotherapy and systemic steroids. Therefore, Xeljanz is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 54-year-old male enrollee has requested reimbursement for the Prometheus diagnostic panel performed on 11/24/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the Prometheus diagnostic panel performed on 11/24/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient presented with an acute undiagnosed infection with negative stool studies. To acquire objective data to provide effective treatment management for this patient the use of the diagnostic panel was indicated. The Prometheus diagnostic panel combines serologic, genetic, and inflammatory markers to help differentiate IBD from non-IBD. The testing at issue was indicated to evaluate whether his symptoms were predictive of IBD or another cause of colitis. Therefore, the testing at issue has been established as 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 54-year-old male enrollee has requested reimbursement for the Prometheus diagnostic panel performed on 11/24/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the Prometheus diagnostic panel performed on 11/24/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the article by Dontan the correlation between serologic markers and genetic variations may contribute to reclassifying IBD into new and more homogeneous subclasses. Their significance in diagnosing populations at risk, such as unaffected relatives of IBD patients and [Crohns disease] CD patients prior to diagnosis, is under current investigation. In sum, the reliance on marker testing to assess whether a patient has IBD, without definitive mucosal inspection and sampling is not the standard of care. All told, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 54-year-old male enrollee has requested reimbursement for the Prometheus diagnostic panel performed on 11/24/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the Prometheus diagnostic panel performed on 11/24/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. To assist in the diagnostic evaluation of patients with suspected IBD, serologic testing is utilized to accurately distinguish patients with IBD from patients with other gastrointestinal disorders. The Prometheus diagnostic panel examines the patterns among multiple classes of markers. This approach is indicated in cases that pose a diagnostic challenge and where the presentation remains confounded despite endoscopic and pathologic testing such as in this patient. Therefore, the testing at issue 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 

A 24-year-old male enrollee has requested reimbursement for office visits, acupuncture and physical therapy provided from 11/05/18 through 2/01/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the records do not indicate that the patient had a condition other than a back sprain/strain injury with persistent mechanical low back pain, with possible radiculitis. These are conditions that heal spontaneously, and symptoms generally improve over time with relative rest and palliative measures, as needed. Palliative measures can form a mainstay of treatment for those with significant persistent symptoms, but no marginal objective benefit in course or outcomes would be expected with formal interventions (including acupuncture, infrared therapy and manual therapy) over independently applied measures, such as topical heat, foam rolling, over the counter analgesics, education and reassurance. Secondary preventive measures, such as education with regards to exercise and lifting technique, can be employed by understanding the specific details regarding how the patient may have sustained the original back injury and, thereby, implementing appropriate measures to mitigate risk of re-injury. In this case, there was insufficient documented history with regards to the specifics of his exercise program. Only exercise time exposure characteristics for his type of exercise (weightlifting) are described. Otherwise, generalized measures, such as strengthening the core and staying active with exercise, could have been pursued. The medical evidence does not support the services at issue in this clinical setting. Therefore, office visits, acupuncture and physical therapy provided from 11/05/18 through 2/01/19 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 28-year-old female enrollee has requested reimbursement for emergency services provided on 4/27/16. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found at issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with a sunburn. She reported pruritis, but declined Benadryl. She denied fever, vomiting, headache, or weakness. The patients pain was rated at 5/10. No blistering of the skin was present. The patient denied any other systemic symptoms. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services provided on 4/27/16 did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The parent of a 14-year-old female enrollee has requested reimbursement for genetic testing performed on 4/30/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees melanoma. The physician reviewer found that the current medical evidence does not support the services at issue. This patient had an early stage melanoma. The National Comprehensive Cancer Network states while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. In addition, the use of DecisionDx-Melanoma testing has not been validated in children. Thus, genetic testing performed on 4/30/18 was not medically necessary 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

A 27-year-old female enrollee has requested authorization and coverage for Humatrope. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has been assessed with adult growth hormone deficiency.  A review of the record indicates that the enrollee has been diagnosed with adult growth hormone deficiency. The enrollee reported that she has been taking the growth hormone since the end of 2010. In a letter dated 9/6/17, the provider reported that the enrollee had a pre-treatment of insulin like growth factor-1 (IGF-1) of 184 ng/mL with a mean of 237 and a range of 87-368. The provider reported that the enrollee started her growth hormone stimulation to assess for growth hormone deficiency and peaked at 5.5 ng/mL. The record indicates that the enrollee had been diagnosed with Cushings syndrome in 2009. The enrollee has requested authorization and coverage for Humatrope.  The Health Insurer indicates that the requested medication is not medically necessary. Per the Health Insurer, the enrollee did not meet the Health Plans clinical criteria for the requested medication. Therefore, the Health Insurer denied coverage for the requested medication.  At issue is whether the requested medication is medically necessary for treatment of this enrollees medical condition.I have determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 58-year-old female enrollee has requested reimbursement for the radiofrequency lesioning performed on 7/7/16 and 7/21/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees thoracic and lumbar degenerative disc disease and facet arthropathy. The physician reviewer found that the literature states that a diagnostic medial branch block is supposed to be done prior to radiofrequency ablation and should include use of a pain diary for the day to verify when the local anesthetic wore off, using either solely lidocaine or bupivacaine, without sedation (Derby, et al). In the documentation available for review, the provider does not document a pain diary for the medial branch block done prior to the previous radiofrequency ablation. Further, the records do not document a steroid injection has been performed, which may provide the patient with identical relief without the increased risks associated with radiofrequency ablation (Manchikanti, et al). Finally, the medical records from the prior ablation are not submitted to demonstrate the patient obtained 50% relief, with increased functional benefit from baseline, and decrease in perceived pain from baseline. For these reasons, radiofrequency lesioning performed on 7/7/16 and 7/21/16, were not medically necessary for treatment of the patients medical condition. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.