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

Summary Reviewer 



A 54-year-old male enrollee has requested authorization and coverage for apremilast (Otezla) 30 mg tablets. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriatic arthritis. The physician reviewer found that the documentation provided do not support the medical necessity for the requested medication in this clinical setting. While the records indicate that this patient has failed two treatments with NSAIDs, the records do not demonstrate that he has tried and failed nonpharmacological treatments (ultravioletlight therapy), disease-modifying antirheumatic drugs (DMARD) therapies, or anti-tumor necrosis factor (TNF) agents. There is also no documentation that he has tried the standard topical therapy to address the psoriasis that covers at least ten percent of his body surface area. While apremilast may represent a promising therapy for the treatment of psoriatic arthritis and psoriasis, the medication should be tried after failure of other standard forms of therapy. Per Zerilli, and Ocheretyaner, Additional long-term studies are needed to further elucidate its place in therapy. As such, the requested medication is not medically indicated for the treatment of this patient. Therefore, for the reasons stated above, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 50-year-old male has requested authorization and coverage for the LINX Reflux Management System.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees gastroesophageal reflux disease. The physician reviewer found the U.S. Food and Drug Administration has approved the LINX Reflux Management System for lower esophageal sphincter augmentation.  Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm.  This patient meets those specific criteria. The device is a ring made up of a series of magnets that have sufficient attraction to increase the lower esophageal sphincter closure pressure, but allow for food passage with swallowing. Based upon a prospective study by Lipham and colleagues which included 44 patients, the mean total percent time pH less than 4 was reduced from 11.9 percent at baseline to 3.8 percent at three years.  A recent study comparing the LINX procedure with laparoscopic fundoplication was performed by Reynolds and colleagues.  This was a retrospective study which used propensity matching to compare groups. The authors found that gastroesophageal reflux disease patients had similar control of reflux symptoms after both LINX and fundoplication. The inabilities to belch and vomit were significantly fewer with LINX, along with a significantly lower incidence of severe gas-bloat symptoms.  In this patients case, the requested LINX Reflux Management System is likely to be superior over 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 Upheld

Summary Reviewer 2


A 50-year-old male has requested authorization and coverage for the LINX Reflux Management System.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees gastroesophageal reflux disease. The physician reviewer found the LINX device has been approved for patients with diagnosed gastroesophageal reflux disease as defined by abnormal pH testing, and who continue to have chronic gastroesophageal reflux symptoms despite maximal medical therapy for the treatment of reflux.  In this patients case, he has acid reflux as based on pH recording.  However, the records document that he has benefited to a significant degree from acid suppression treatment, and as such cannot be considered medically refractory when compliant with daily acid blocker drug use.  Also, implantation of LINX in this setting must be approached with caution given his documented complaints of globus.  Therefore, the requested LINX Reflux Management System is not likely to be of greater benefit than other treatment options.  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 Upheld

Summary Reviewer 3


A 50-year-old male has requested authorization and coverage for the LINX Reflux Management System.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees gastroesophageal reflux disease. The physician reviewer found there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures.  Sheu and Rattner concluded that the long-term safety and efficacy of LINX remains to be determined.  Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval.  Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication.  Thus, the LINX Reflux Management System is not likely to be more effective than other treatment alternatives.  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 Upheld

Summary Reviewer 1

A 63-year-old male enrollee has requested reimbursement for the Foundation One test performed on 3/13/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees metastatic poorly differentiated carcinoma. The physician reviewer found that the utility of the Foundation One testing has not been demonstrated to improve patient outcomes as compared to standard testing. According to the National Comprehensive Cancer Network (NCCN), to demonstrate clinical utility of panel genetic testing such as Foundation One, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. The available literature on clinical utility consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. This evidence is not sufficient to make conclusions on clinical utility. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the Foundation One test provided on 3/13/16 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 2

A 63-year-old male enrollee has requested reimbursement for the Foundation One test performed on 3/13/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees metastatic poorly differentiated carcinoma. The physician reviewer found that Foundation One testing offers a comprehensive panel of molecular genetic markers on an individual patients tumor in an attempt to identify markers than can help guide therapy decision making. Per the National Comprehensive Cancer Network (NCCN) guidelines, it has not been determined if molecular markers are useful in treatment determination and prognosis other than the tests developed for localized prostate cancer. The National Cancer Institute (NCI) is currently conducting a phase II clinical trial evaluating the efficacy of genetic molecular testing to guide individual patient therapy. As Foundation One provides genetic testing to guide therapy and this is the subject of an ongoing phase II trial its use remains investigational at this time. Accordingly the Foundation One test performed on 3/13/16 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 63-year-old male enrollee has requested reimbursement for the Foundation One test performed on 3/13/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees metastatic poorly differentiated carcinoma. The physician reviewer found that the Foundation One test analyzes 200 oncogenes and tumor suppressor genes for mutations by next generation sequencing. The results can assist providers in selecting treatment towards these mutations. Von Hoff and colleagues reported on a study of 86 patients where the progression free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The authors found that the regimen selected by molecular profiling offered a 27% survival advantage. Two clinical trials compared cabozantinib to placebo and showed that the drug extended PFS, decreased opiate use in patients, treated soft tissue and bone lesions, and decreased markers of bone turnover (Smith, et al; Goodin and DiPaola). Given this support, the Foundation One test provided on 3/13/16 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 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 55-year-old female enrollee has requested reimbursement for inpatient services provided on 4/03/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees palpitations. The physician reviewer found that the patient presented with complaints of tinnitus without any other neurologic complaints. She was hemodynamically stable, without any neurologic deficits on examination. The inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. Thus, inpatient services provided on 4/03/17 were not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1
A 51-year-old female enrollee has requested reimbursement for the MammaPrint genetic test provided on 2/3/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees left breast carcinoma. The physician reviewer found that the decision to use adjuvant chemotherapy is typically based on the pathologic details of an individual patients breast cancer as well as genetic analyses in certain situations. The OncotypeDX and MammaPrint gene assays can help determine whether an individual patient is at low or high risk of recurrence. Patients at high risk are often recommended to receive adjuvant chemotherapy (Cardoso, et al). In this case, the OncotypeDX assay placed this patient in an intermediate risk category. In this clinical setting, the provider will likely recommend adjuvant chemotherapy given the positive node and intermediate results on OncotypeDX. In view of her nodal positivity, the MammaPrint genetic test provided on 2/3/16 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 2

A 51-year-old female enrollee has requested reimbursement for the MammaPrint genetic test provided on 2/3/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees left breast carcinoma. The physician reviewer found that in the peer-reviewed medical literature, there is inadequate data demonstrating that a high risk MammaPrint result is a reliable indication for chemotherapy. Further, there is currently a lack of data to support using MammaPrint testing in patients with intermediate OncotypeDX score. Although Cardoso and colleagues reported that MammaPrint has been shown to improve prediction of clinical outcome in women with early-stage breast cancer, this patient already underwent genetic testing with OncotypeDX and was noted to have lymphovascular invasion. Thus, additional genetic testing was not needed for decision making regarding adjuvant chemotherapy. All told, the MammaPrint genetic test provided on 2/3/16 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 51-year-old female enrollee has requested reimbursement for the MammaPrint genetic test provided on 2/3/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees left breast carcinoma. The physician reviewer found that early breast cancer that is hormone receptor positive can be treated with tamoxifen alone in postmenopausal women. In that instance, there is a 15% chance of recurrence. It is this 15% that needs adjuvant chemotherapy (Paik, et al). There are several established biomarkers that are prognostically valuable in breast cancer. These include the presence of estrogen or progesterone receptors, HER2 amplification, as well as proliferative index, and histologic grade. Newer technologies such as gene expression such as the MammaPrint may also classify tumors to basal-like or luminal-type of disease. Since the OncotypeDX test returned intermediate results that did not allow a definitive decision on adjuvant treatment, the MammaPrint genetic test provided on 2/3/16 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 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 

A 59-year-old female enrollee has requested authorization and coverage for lumbar spine decompression and fusion. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient presents with worsening low back pain radiating down the right lower extremity in an L4 distribution with associated numbness and tingling. Significant functional limitations are noted in activities of daily living and mobility. Her signs and symptoms are reported as positional and consistent with neurogenic claudication. She has failed to achieve adequate relief with long-term conservative treatment. Clinical examination findings have evidenced reflex changes consistent with imaging evidence of nerve root compromise and prominent facet degenerative change with facet cysts at the L4-5 and L5-S1 levels. There is reported radiographic evidence of spondylolisthesis at L4-5 and L5-S1 with spinal instability reported of 6-10 mm. Additionally, there is plausible need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. The medical literature supports lumbar decompression and fusion in this clinical setting. Therefore, the requested lumbar spine decompression and fusion is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


An 82-year-old female enrollee has requested authorization and coverage for Elidel 1% cream. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees decubitus wound on the lateral aspect of the left foot.   The physician reviewer found this patient was diagnosed with an inflammatory skin condition consistent with atopic dermatitis. The records provided for review document that the patient was treated with multiple modalities including topical steroids without substantial improvement. In this clinical setting, the continued use of Elidel is indicated. Therefore, the requested Elidel 1% cream is supported as medically necessary for treatment of this patients persistent skin condition. Based on these findings, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 29-year-old female enrollee has requested reimbursement for the laboratory testing (CPT 86038, 86644, 82728, 82746, 82784, 85682, 84480, 84479, 80061, 82607, 36415, 86665, 86664, 83540, 83550, 80074, 86645, 86663, 82306, 84481, 80050, 86039, 81261, 81264, 81342, 81340, 84999, and 86790) provided on 8/16/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees body aches, low grade fever and fatigue. The physician reviewer found that according to the records provided for review, this patient presented with nerve tingling, headaches, muscle spasms, fatigue and body aches. The constellation of symptoms does not suggest the requested testing strategy was indicated for diagnosis of this patients medical condition. Specifically, the patient did not meet the standard clinical scenario for the evaluation of a lymphoproliferative disorder (Styczynski, et al; Ok, et al). Therefore, the laboratory testing (CPT 86038, 86644, 82728, 82746, 82784, 85682, 84480, 84479, 80061, 82607, 36415, 86665, 86664, 83540, 83550, 80074, 86645, 86663, 82306, 84481, 80050, 86039, 81261, 81264, 81342, 81340, 84999, and 86790) provided on 8/16/17 was not medically necessary for evaluation of the patients medical condition. Based on the foregoing discussion, 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 39-year-old male enrollee has requested authorization and coverage for Staxyn, eight tablets per month. The Health Insurer has denied this request and reported that the requested medication quantity is not medically necessary for treatment of the enrollees erectile dysfunction.  A review of the record indicates that the enrollee has been diagnosed with erectile dysfunction. Per the submitted documentation, the enrollee was prescribed Staxyn for treatment of this condition. The enrollee reported that his provider has recommended eight tablets per month, and the Health Insurer has only covered three tablets per month.  The Health Insurer indicated that the requested medication quantity is not medically necessary for treatment of the enrollees medical condition. Therefore, the Health Insurer has denied coverage for the requested medication quantity.  At issue is whether the requested medication quantity is medically necessary for treatment of the enrollees medical condition.The Health Insurers quantity limit of the requested medication is three tablets per month. I have determined that the requested medication quantity 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 Overturned

Summary Reviewer 

A 39-year-old female enrollee has requested reimbursement for emergency and post stabilization services and care provided from 5/01/19 through 5/04/19. 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 evidence-based medical literature generally support open reduction and internal fixation of unstable ankle fractures several days to a few weeks after injury. Continued inpatient admission is indicated until acceptable patient status for next level of care is achieved, including pain is absent or adequately managed on oral medications, injuries stabilized as needed (e.g. cast, orthoses), and the patient is ambulatory and can perform activities of daily living or activity at baseline or activity acceptable for next level of care. This patient sustained a left trimalleolar displaced fracture on 5/01/20. She was admitted to inpatient care with severe swelling of the left foot and toes for surgical management. She was provided inpatient care, including ongoing intravenous fluids, lower extremity neurovascular checks, preoperative cardiac evaluation, swelling reduction, deep vein thrombosis prophylaxis, and pain management in the preoperative period. She underwent open reduction and internal fixation of the left ankle fractures on 5/04/19 and was subsequently discharged home. The services provided in the emergency and inpatient setting as outlined above would appropriately be considered acute level of care for treatment of the enrollees acute displaced ankle fracture. Based on the records, emergency and post stabilization services and care provided from 5/01/19 through 5/04/19 were medically necessary for the treatment of this patient.