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

Summary Reviewer 2

The patient is a 36-year-old female with dysmenorrhea which was interfering with her quality of life. She opted for an endometrial ablation for treatment.  The patient tried oral contraceptive pills. However, she failed this treatment due to headaches. The patient is a smoker, and her partner has had a vasectomy. On 12/30/16, endometrial ablation was performed. The Health Insurer has denied reimbursement for the services at issue. Per the Health Insurer, endometrial ablation was investigational for the treatment of this patient. There is sufficient support for the services at issue in this clinical setting. Endometrial ablation is an effective, minimally invasive treatment for heavy menstrual bleeding. There are several techniques available, and all techniques have been shown to reduce menstrual bleeding by a statistically significant amount. This is a useful treatment for avoiding hysterectomy and was an appropriate choice for this patient. Thus, endometrial ablation performed on 12/30/16 was likely to have been of greater benefit than other available treatment options. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

The patient is a 36-year-old female with abnormal uterine bleeding. She reported heavy menstrual cycles with cramping affecting her quality of life. She tried hormonal options for medical management with birth control pills in November 2016, but experienced headaches. A pelvic ultrasound was performed showing no intracavitary abnormalities.  On 12/30/16, endometrial ablation was performed. The Health Insurer has denied reimbursement for the services at issue. Per the Health Insurer, endometrial ablation was investigational for the treatment of this patient. The medical evidence does not support the services at issue in this clinical setting. An endometrial ablation is a minimally invasive technique used to destroy the uterine lining for the treatment of chronic menorrhagia/abnormal uterine bleeding. This technique is supported by peer-reviewed current medical literature in patients who no longer desire fertility and in whom a thorough work-up has been performed to rule out other causes of abnormal uterine bleeding. This evaluation includes performing a pelvic ultrasound and an endometrial biopsy or dilation and curettage (D&C).  Furthermore, the patient should have tried and failed medical management options over a reasonable period of time. Alternative treatment options, including hormones (pills, intrauterine device) and surgery, should be discussed and documented in the medical records. In this patients case, there was a lack of clinical documentation regarding the duration of her symptoms. The patient no longer desired fertility. She trialed a course of hormonal management with oral contraceptives, although, the overall duration of this treatment and failure is not clearly documented. Additionally, there is no documentation to support an evaluation of her endometrial lining to rule out endometrial hyperplasia or malignancy by biopsy or D&C.  Finally, there is no clinical documentation to support a discussion of all her options prior to proceeding with endometrial ablation. Thus, endometrial ablation performed on 12/30/16 was not likely to have been more efficacious than other available treatment options. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 29-year-old female with a history of injury to the lower back while cheerleading, with associated chronic low back pain. The patient has requested authorization and coverage for lumbar spinal surgery at L5-S1 and one inpatient day. The Health Insurer has denied this request indicating that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that degenerative lumbar pathologies are commonly encountered at the lumbosacral junction. These include disc degeneration, ligamentum flavum hypertrophy, neural foraminal stenosis, and other causes of pain or neurologic deficit with associated radiculopathy. Conservative treatment should be tried first, as in this case. When conservative fails, surgical intervention at the lumbosacral junction becomes necessary. Surgery consists of decompression and stabilization of the level involved to maximize pain relief and relieve neural compression and reverse the radiculopathy, while maintaining the strength, function, and stability of the spine, and preventing adjacent level degeneration. In this case, there is documented failure of conservative treatments, including physical therapy and corticosteroid injections. As such, surgery is necessary. Documentation indicates the pain generator is L5-S1. Surgery has a good prognosis, and she is a good candidate. Therefore, the requested lumbar spinal surgery at L5-S1 and one inpatient day are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

This patient is a three-year-old female who was admitted to Presbyterian Hospital in Albuquerque, New Mexico on 7/15/18. While on vacation in New Mexico, she developed a fever. She was initially evaluated and diagnosed with a viral illness. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. Non-emergency air ambulance transportation for inter-facility transfers is considered medically necessary when a patient is medically stable and requires a higher level of care or services that cannot be provided at the sending institution. In such cases, the patient is transferred to the closest facility capable of provided the needed services. In this case, the documentation supports that the patient was transferred from Presbyterian Hospital in Albuquerque, New Mexico to Ann and Robert H. Lurie Children Hospital in Chicago, Illinois in order to be closer to home. The patient was receiving appropriate care. Her condition was noted to be medically stable, and she was discharged home four days after her transfer. Therefore, air ambulance provided on 7/21/18 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The parent of a 16-year-old female enrollee has requested authorization and coverage for ceftriaxone sodium injection. The Health Insurer has denied this request indicating that the requested medication is at investigational for the treatment of the enrollees Lyme disease. The physician reviewer found per Infectious Disease Society of America practice guidelines and the peer-reviewed literature, there is a lack of data to support the use of IV ceftriaxone therapy for more than four weeks for the treatment of Lyme disease. Also, the patients diagnosis of Lyme disease is not definitive based on the clinical documentation submitted for review. Given the lack of documentation of support for a diagnosis of Lyme disease and the lack of data supporting prolonged therapy with ceftriaxone sodium injection, the requested medication is not clinically indicated. Based upon the information set forth above, the requested medication is 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 2

The parent of a 16-year-old female enrollee has requested authorization and coverage for ceftriaxone sodium injection. The Health Insurer has denied this request indicating that the requested medication is at investigational for the treatment of the enrollees Lyme disease. The physician reviewer found the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The diagnosis of chronic Lyme disease is controversial. This is due to the inability of clinicians to consistently and reliably diagnose this disorder via laboratory testing. In addition, most accepted practice guidelines suggest the maximum length of antibiotic therapy for Lyme disease is four weeks. This is even for those individuals who have late disease with neurological complications. In multiple studies there has been no benefit shown in patients who have received antibiotics for greater than 28 days compared to those who have not.  Moreover, long-term use of IV antibiotics carries significant risks including liver disease, anaphylaxis, and candidemia. The relation between CD8-CD57 cell counts/percentage and Lyme disease has been addressed sparsely in the medical literature despite anecdotal claims of these lymphocyte surface markers being an indicator of Lyme disease activity.  Furthermore, the majority of patients who have epidemiological, clinical, and laboratory evidence of Lyme disease only require 13 days of therapy, usually oral. As such, the continued use of ceftriaxone sodium injection is not likely to be more beneficial treatment than standard medical therapy in this clinical setting. Based upon the information set forth above, the requested medication is 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


The parent of a 16-year-old female enrollee has requested authorization and coverage for ceftriaxone sodium injection. The Health Insurer has denied this request indicating that the requested medication is at investigational for the treatment of the enrollees Lyme disease. The physician reviewer found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with a diagnosis of chronic Lyme disease and is requesting an extended intravenous therapy with ceftriaxone. However, per the documentation submitted for review, the patients symptoms are not consistent with Lyme disease and there are no abnormal physical exam findings. In addition, the there was no Western blot submitted or Centers for Disease Control and Prevention criteria based immune assay for Borrelia burgdorferi. Moreover, the studies in the peer-reviewed literature have not supported the use of long term or extended therapy for the treatment of Lyme disease beyond four weeks. Thus, infusion medication with ceftriaxone is not likely to be more beneficial treatment than standard medical therapy in this clinical setting. Based upon the information set forth above, the requested medication is 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

The patient is a 62-year-old male who had a prostate biopsy on 7/11/16. At that time, his prostate specific antigen score was less than 10. Of 14 cores taken, one was positive for Gleason 3+3 (6) adenocarcinoma, occupying 8% of the core. A tissue sample was sent for OncotypeDx assay. The patient has requested reimbursement for gene expression profiling OncotypeDX prostate cancer assay performed on 2/14/17. The Health Insurer has denied this request and noted that the services at issue were investigational for evaluating this patients medical condition. The standard of care after the initial diagnosis of localized prostate cancer is to determine a specific cancer treatment such as surgery or radiation therapy, or undergo active surveillance, with no specific treatment at that time. A recommendation is made based on risk stratification, which is a methodology placing each man into a risk category for which a treatment can be recommended. The stratification is mostly based on the prostate specific antigen and specific pathologic findings at biopsy. Applying this methodology to this patient, he falls into a very low risk category, for which surveillance alone would be the recommendation. A further refinement of prognostication is the use of gene panels, such as OncotypeDx. This is a 17 gene panel that seems capable of predicting the risk of recurrence after treatment, such as surgery, for the prostate cancer (Cheville et al; Cullen, et al). While there have been multiple genetic profiles studied to investigate whether these assays might add to the accuracy of prognostic categorization by risk assessment, these tests have not yet been shown to be reliable in altering clinical decision making, particularly in patients assessed in the very low risk category, such as is the case in this patient. All told, the gene expression profiling OncotypeDX prostate cancer assay performed on 2/14/17 was not likely to have been of greater benefit over the standard methods of evaluating this patients medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been 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 2

The patient is a 62-year-old male with a T1c Gleason 3+3 prostate cancer. His tumor was sent for OncotypeDX Prostate Cancer on 2/14/17 to help guide treatment decision making. The Health Insurer has denied this request indicating that the services at issue were considered investigational for the evaluation of the patients prostate cancer. The patient has requested reimbursement for the gene expression profiling OncotypeDX prostate cancer assay performed on 2/14/17. The Health Insurer has denied this request on the basis that the services at issue were investigational for the evaluation of this patients medical condition. The National Comprehensive Cancer Network (NCCN) recommends testing with OncotypeDX post biopsy for NCCN very low and low risk prostate cancer in patients with at least 10 years life expectancy who have not received treatment for prostate cancer and are candidates for active surveillance or definitive therapy. Men with clinically localized disease may consider the use of tumor based molecular assays. Retrospective case cohort studies have shown that molecular assays performed on biopsy or prostatectomy specimens provide prognostic information independent of NCCN risk groups. These include, but are not limited to, likelihood of death with conservative management, likelihood of biochemical progression after radical prostatectomy or external beam therapy, and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. The OncotypeDX assay is considered standard of care in guiding treatment decision making for patients with low risk prostate cancer. Accordingly, the gene expression profiling OncotypeDX prostate cancer assay performed on 2/14/17 was likely to have been more beneficial than any available standard therapy for the evaluation of this patients medical condition.  Therefore, for the reasons stated above, the services at issue were likely to have been 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

The patient is a 62-year-old male with prostate cancer. The record noted the patient had an elevated prostate specific antigen (PSA) of 8.5 ng/mL. He had a prostate core biopsy performed that showed adenocarcinoma of Gleason score of 3+3=6, involving less than 50% of the gland. An OncotypeDX test was ordered to better determine adjuvant treatment or observation. The patient underwent testing and has requested reimbursement for the gene expression profiling OncotypeDX prostate cancer assay performed on 2/14/17. The Health Insurer denied the request for reimbursement. Per the Health Insurer the services at issue were investigational for the evaluation of this patients medical condition. Once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features such as the grade of tumor and PSA level. This helps guide the most appropriate therapy for patients taking into account their age and co-morbidities because many patients will not require therapy (i.e., surgery or radiation) and instead, may be followed closely. Current biomarkers are inadequate for risk stratification and better prognostic biomarkers are needed. The prostate Oncotype DX is a gene expression analysis that target genes in the biopsy specimen and generates a genomic prostate score (GPS). A validation study was presented at the American Urological Association meeting in 2013 involving 395 patients (Cooperberg, et al). The GPS identified patients that had very low risk disease that could be followed rather than referred for surgery. Current prognostic features are inadequate to make firm recommendations regarding active surveillance to patients. In addition, the National Comprehensive Cancer Network guidelines appear to suggest that the OncotypeDX test is a technique that is able to better stratify patients with localized disease. As such, the gene expression profiling OncotypeDX prostate cancer assay performed on 2/14/17 was likely to have been more effective than any available standard method for evaluating this patients medical condition.  Therefore, for the reasons stated above, the services at issue were likely to have been 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 48-year-old male enrollee has requested authorization and coverage for arthrodesis sacroiliac joint. 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 a history of chronic left sacroiliac joint/buttock pain which radiates into the posterior thigh. Significant functional limitations are noted in activities of daily living due to his left sacroiliac joint pain, including sleep disruption. Clinical examination findings have documented positive Fortin finger test for left sacroiliac joint pain and positive sacroiliac joint provocative tests. He had positive short-term response to sacroiliac joint corticosteroid and platelet-rich plasma injections, followed by the return of severe pain. He has failed to achieve adequate sustained relief with prior injection therapy, extensive physical therapy, activity modification, and medications. There is reported imaging evidence of left sacroiliac joint degenerative changes. There is also magnetic resonance imaging (MRI) evidence of L5/S1 spondylolisthesis and neural foraminal stenosis with bilateral L5 nerve root compression. The records documented current normal lumbar spine examination with no lower extremity focal neurologic deficits, and normal bilateral hip examination. A recent L5/S1 selective nerve root block did not provide significant relief of symptoms. It is documented that the lumbar spine and left hip have been ruled-out as the primary pain generators. He has been recommended for minimally invasive left sacroiliac joint fusion. Current evidence-based medical literature and guidelines support the use of the minimally invasive sacroiliac joint fusion in this clinical setting. Therefore, sacroiliac joint arthrodesis is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 48-year-old female enrollee has requested reimbursement for lab testing (Factor V Leiden genetic testing) provided on 12/16/14. 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 testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  There is a lack of current medical recommendation from national societies, including the American College of Obstetrics and Gynecology (ACOG), for such screening before the prescribing or use of HRT. Such testing in the general population has not been shown to impact on the safety or risk of using HRT across the population. The ACOG Bulletin on prevention of deep vein thrombosis (DVT) addresses who would benefit from such testing stating Because of the high prevalence of the Factor V Leiden mutation in the Caucasian population, all patients who are not Hispanic, Asian, or African American and have a history of DVT may be tested. In non-Caucasian patients, the decision to test should be individualized. Patients with histories of extensive or recurrent thrombosis or family histories of thrombosis may have the Factor V Leiden mutation in combination with another congenital or acquired disorder. In this case, the patient was asymptomatic with no personal or family history of thrombosis. The testing performed was not indicated or likely to be more beneficial for evaluation of the patients medical condition than other modalities. 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 48-year-old female enrollee has requested reimbursement for lab testing (Factor V Leiden genetic testing) provided on 12/16/14. 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 testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Although there is an increased risk of a thrombotic event with hormone use, in the population as a whole the overall risk of a thrombotic event is still small. This low risk to the general population is especially true if women with known risk factors are pulled from the general population and screened. Currently, given these facts, the current recommendations suggest that only those with specific risk factors should be screened. The documentation submitted for review does not demonstrate that the patient has had a venous thrombosis, pulmonary embolism, family histories, or adverse pregnancy events. All told, the testing at issue was not likely to be superior for evaluation of the patients medical condition than other modalities.