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

Summary Reviewer 1

A 56-year-old male enrollee has requested reimbursement for service code 84999, OncotypeDX prostate cancer assay completed on 6/6/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that the medical evidence has not demonstrated the superior efficacy of the services at issue in this clinical setting.  There are three major therapeutic approaches to the management of apparently localized prostate cancer. These include radical prostatectomy, radiation therapy, and surveillance with no specific treatment.  Recommendations are made as to these options based on risk stratification, meaning an estimate of the risk for the future development of recurrence. The patients prostate cancer is evaluated with a combination of clinical features, prostate-specific antigen, and pathologic features. Thus, patients essentially can be placed into four categories: very low-risk, low-risk, intermediate risk, and high-risk. Based on the records, this patient would be placed in a very low-risk category for which active surveillance would be a good option. A further refinement of prognostication is the use of gene panels, such as OncotypeDX. This is a 17 gene panel that is capable of predicting recurrence of prostate cancer after treatment (Cheville, et al; Cullen, et al).  However, this test has not been clinically validated (Moschini, et al). Moreover, it is particularly speculative as to whether it would be useful in this specific patient who was assessed with very low-risk disease. All told, service code 84999, OncotypeDX prostate cancer assay completed on 6/6/16 was not likely to have been more effective than the available treatment options for the evaluation of this patient. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for the 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


[INSERTA 56-year-old male enrollee has requested reimbursement for service code 84999, OncotypeDX prostate cancer assay completed on 6/6/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that there are medical studies that support the efficacy of the services at issue in this clinical setting. Molecular assays have been developed in an effort to improve decision making for those patients who have been newly diagnosed. These assays have also been utilized for those patients who are already in treatment but may be considering adjuvant therapy or treatment for recurrence. For patients with clinically localized disease, tumor based molecular assays may also be considered. Retrospective case cohort studies have shown that molecular assays performed on biopsy or prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network (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. There are several test available and recommended by the NCCN guidelines, including OncotypeDx prostate. In this patients case, he meets the NCCN criteria.  In sum, service code 84999, OncotypeDX prostate cancer assay completed on 6/6/16 was likely to have been more effective than the standard treatment options for the evaluation of this patient. Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for the 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 56-year-old male enrollee has requested reimbursement for service code 84999, OncotypeDX prostate cancer assay completed on 6/6/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer.The physician reviewer found that the medical evidence supports that the OncotypeDX assay can be used to better stratify such patients with localized disease. 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 prostate-specific antigen level. This helps guide the most appropriate therapy for patients taking into account their age and comorbidities because many patients will not require therapy (i.e., surgery or radiation) and may be followed closely instead. Current biomarkers are inadequate for risk stratification and better prognostic biomarkers are needed. The Prostate OncotypeDX is a gene expression analysis that targets genes in the biopsy specimen that 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. The current prognostic features are inadequate to make firm recommendations regarding active surveillance to patients. The National Comprehensive Cancer Network (NCCN) guidelines also suggest the OncotypeDX test to better stratify such patients with localized disease. In sum, service code 84999, OncotypeDX prostate cancer assay completed on 6/6/16 was likely to have been more efficacious than the other treatment options for the evaluation of this patient. Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for the 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 patient is a 58-year-old female who presented in August 2019 with back pain. The patient has requested authorization and coverage for CT of thorax, abdomen and pelvis. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient. The physician reviewer found that the requested CT scan of the abdomen/pelvis is not indicated. In this patientas case, there has not been any involvement in the soft tissues below the diaphragm. The records also fail to demonstrate the medical necessity of the requested CT scan of the thorax. Much has been written concerning the appropriate schedule for imaging follow-up of lung cancer. However, many of these studies have referenced lung cancer that is not as advanced as in this patient. For instance, the National Comprehensive Cancer Network (NCCN) recommends for stage I and stage II that CT scans be obtained every three to six months for three years, and then every six months for two years, and then annually thereafter. These recommendations, however, were made for patients after definitive therapy, where a cure is suspected. For more advanced stages of non-small cell lung cancer, the NCCN guidelines are less precise, and indicate that imaging should be individualized. The American Society of Clinical Oncologists has also established guidelines for surveillance scanning following treatment for lung cancer. However, their guidelines are similarly established for curative-intent therapy, not for advanced stage IV disease. Their guidelines are similar to the NCCN guidelines. Schneider points out in his summary, aathere are insufficient data to support different surveillance strategies based on disease stage in patients not actively receiving cancer-directed therapy, including stage III non-small cell lung cancer and stage I-III small cell lung cancer. Although more frequent imaging may detect asymptomatic recurrences earlier, this does not translate into a survival benefit in the available studies. As a basic concept, imaging is only indicated when it will affect patient management. In this particular patient, with moderate improvement and no significant acute symptoms, it is likely unnecessary to obtain imaging at such frequent intervals. As with any tumor, changes are not likely to happen rapidly, and it is often more advantageous to have comparison studies performed at wider intervals. For this patient, scans every three months are likely too frequent. If the referring physician is considering altering her therapy, then a follow-up CT scan of the chest may be warranted at the six-month interval. In order to better evaluate the bone metastases, the CT scan is likely not the most optimal study. Therefore, the requested CT of thorax, abdomen and pelvis is not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 61-year-old male with a history of hypothyroidism on escalating doses of levothyroxine.  The patient has requested reimbursement for the ultrasound of the soft tissues of head and neck performed on 1/12/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that Hypothyroidism affects up to 5% of the general population, with a further estimated 5% being undiagnosed. Hypothyroidism is diagnosed biochemically, being overt primary hypothyroidism defined as serum thyroid stimulating hormone (TSH) concentrations above and thyroxine concentrations below the normal reference range. Although studies have demonstrated that patients diagnosed with hyperthyroidism, thyroiditis, goiter, and adenoma had significantly elevated risks of differentiated thyroid cancer, there does not appear to be an association between a history of hypothyroidism and risk of thyroid cancer. Thyroid ultrasonography is not indicated as part of routine workup of hypothyroidism. Therefore, the ultrasound of the soft tissues of head and neck performed on 1/12/21 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 53-year-old female enrollee has requested authorization and coverage for a transcatheter aortic valve replacement (TAVR). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that based on current guidelines, including the recent Partner 3 Trial, TAVR is considered superior to surgical aortic valve replacement (SAVR) in low risk patients with severe aortic stenosis. The one-year outcomes showed a significantly lower composite of death, stroke or re-hospitalization. However, as in prior TAVR trials, patients were excluded if they did not have severe aortic stenosis (a transvalvular gradient of at least 40 mmHg) and if the valve was bicuspid, as is the case with this who has a bicuspid valve and a gradient of only 26 mmHg. Therefore, the patient would not meet inclusion criteria in the relevant TAVR trials. Therefore, the requested TAVR is not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 53-year-old female enrollee has requested authorization and coverage for a transcatheter aortic valve replacement (TAVR). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the patient has severe aortic stenosis and requires valve replacement. She has a bicuspid valve, and given her age, she would likely need at least two chest surgeries owing to bioprosthetic valve degeneration over her lifetime. Her providers would like to initially attempt TAVR to obviate the need for surgical valve replacement at least until she reaches her 60s. TAVR has been studied and used successfully in low risk patients in a number of randomized published trials and carries an U.S. Food and Drug Administration (FDA) approval for this indication. The risk/benefit has been carefully weighed by the treating providers and the patient and an initial plan for non-surgical TAVR was made using the heart team and a shared decision making model based on AHA/ACC recommendations. There is support for the requested services in this clinical setting. Therefore, the requested TAVR is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 53-year-old female enrollee has requested authorization and coverage for a transcatheter aortic valve replacement (TAVR). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. TAVR is indicated for patients with symptomatic severe aortic valve stenosis and either intermediate or high surgical risk for open aortic valve replacement surgery. This patient would be considered low surgical risk by the information provided. Although recent data has evaluated lower risk patients for TAVR, they have generally excluded patients with bicuspid aortic valves such as with this patient, they required higher baseline gradients for eligibility compared to this patient, and there is no long-term follow-up beyond one year. Therefore, the requested TAVR is not likely to be more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 39-year-old male enrollee has requested reimbursement for the inpatient hospital stay services provided from 9/21/15 through 9/27/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees degenerative disc disease (DDD) with herniations. The physician reviewer found the current medical literature with regard to two level total disc replacement in the lumbar spine includes varying outcomes. In a recent article published by Trincat and colleagues, the authors noted that two level lumbar disc replacement can improve spinal function while preserving its mobility but the procedure is fraught with risks and complications. Thus, longer follow-up is needed to evaluate the sustainability of the results and to detect any adjacent segment disease. A high-quality meta-analysis and health technology assessment concluded that there is insufficient evidence to draw extensive efficacy conclusions comparing artificial disc replacement with a broad range of recommended treatment options in the lumbar spine (Park, et al). All told, the efficacy remains uncertain and inadequate evidence exists to establish long-term benefits or harms. For these reasons, the inpatient hospital stay services provided from 9/21/15 through 9/27/15 were not medically necessary for treatment of this 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.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


An 18-year-old female enrollee has requested reimbursement for the gene testing performed on 9/1/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees major depressive disorder. The physician reviewer found that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Although, more research is needed to fully develop its potential, there is growing support for genetic testing for psychoactive drugs. In this case, the patient has not tolerated most standard mood stabilizers. The test results show that she will likely have problems tolerating antipsychotic medications, which are commonly used as mood stabilizers. She will also have difficulty tolerating any SSRIs, which are the primary treatment for both anxiety and depression. Therefore, this patients circumstances support genetic testing in this specific clinical setting. Therefore, the gene testing performed on 9/1/16 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


An 18-year-old female enrollee has requested reimbursement for the gene testing performed on 9/1/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees major depressive disorder. The physician reviewer found that genetic testing results show if a patient is a normal responder of certain classes of medications, may be more or less likely to respond to certain medications, is at low risk of certain adverse events, at higher risk of others, or may have decreased activity of a certain enzyme activity. However, the fact that there was a gene mutation does not demonstrate that the addition of l-methylfolate will have an effect on this patients treatment. The length of time she was treated with these medications was not given, nor does she appear to have been tried on other classes of antidepressants. All of these issues could have been assessed by the provider during follow-up, and adjusted for by changes in medication regimen including increased/decreased dose, other augmentation strategies, or discontinuation for a variety of reasons. In addition, plasma levels may be higher or lower due to differences in hepatic metabolism that varies in every individual. Furthermore, there is a lack of large randomized trials supporting the use of genetic testing as effective in guiding the clinician towards choosing a medication regimen. Accordingly, the gene testing performed on 9/1/16 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


An 18-year-old female enrollee has requested reimbursement for the gene testing performed on 9/1/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees major depressive disorder. The physician reviewer found that in general, the practice of pharmacogenetics, or the tailoring of a medication regimen based on an individual patients genetic organization, may become a valuable tool in the treatment armamentarium for those plagued with psychiatric illness. However, despite its promise, pharmacogenetics is not yet ready for routine clinical application as the relatively small, short-term studies to date have not been replicated on a larger scale. In addition, the American Psychiatric Association (APA) did not endorse such testing per current clinical practice guidelines. In this case, there was no clinical data provided to support genetic testing. Notably absent was the documentation of the longitudinal illness burden and extent of impairment at the time, family history, developmental history, social history, psychosocial stressors and medical comorbidities. In sum, considering the relevant peer-reviewed literature and current practice standards, it is not possible to assert with any degree of confidence that the disputed gene test yielded information that significantly influenced treatment decisions, improved the patients condition, prevented a more serious episode of illness or reduced morbidity. Thus, the genetic testing performed on 9/1/16 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 53-year-old male enrollee has requested reimbursement for inpatient hospital stay from 12/20/16 through 12/24/16.  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 the submitted documentation supports the medical necessity of a portion of the services at issue.  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 with new onset atrial fibrillation and could have been treated at a lower level of care. At the time of admission, the patient was afebrile with a normal white blood cell count and was hemodynamically stable without evidence of congestive heart failure.  On 12/22/16, the patient was noted to have worsening abdominal pain with a worsening leukocytosis and imaging consistent with acute cholecystitis.  Given the patients recent arrhythmia and need for anticoagulation, the patient was at high risk for perioperative complications. Therefore, a cholecystostomy catheter was placed for drainage. In this case, the patients clinical course worsened.  Given the potential for cardiac complications, acute inpatient medical admission from 12/22/16 through 12/24/16 was medically necessary. However, inpatient hospital stay from 12/20/16 through 12/21/16 was not medically necessary for the treatment of this patient. Therefore, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 59-year-old female enrollee has requested reimbursement for Harvoni. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found the submitted documentation supports the medical necessity of the medication at issue.  According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy less than 12 months due to non-liver-related conditions.  The guidelines support Harvoni for treatment-naive patients with hepatitis C, genotype 1.  It is advantageous to treat patients at an earlier stage of liver fibrosis.  All told, Harvoni was medically indicated for the treatment of this patient.  Therefore, the medication at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.