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

Summary Reviewer 3


A 53-year-old female has requested reimbursement for advanced lipoprotein testing.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the current guidelines do not recommend routine use of advanced lipoprotein tests, mainly because it is unclear how much incremental prognostic information is provided by these tests beyond that available from a standard lipid panel.  To date, the most useful measures obtained from lipoprotein tests relate to atherogenic particle number.  However, at this time, non-high-density lipoprotein (HDL) cholesterol or the total/HDL cholesterol ratio is of comparable predictive strength.  Low-density lipoprotein (LDL) sub-fractions measurement may provide some information regarding risk, but whether this is incremental beyond the current standard of care is unclear.  In this patients case, she was already on statin therapy for elevated cholesterol.  As such, and given the other known baseline coronary risk factors (hypertension, hyperlipidemia, prediabetes), there is no additional diagnostic or prognostic information to be gleaned by the testing at issue.  Thus, advanced lipoprotein testing performed on 3/15/16 was not likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were 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 Upheld

Summary Reviewer 


A 43-year-old male enrollee has requested authorization and coverage for the medication Ocrevus injection 300/10 mL. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees remitting relapsing multiple sclerosis. The physician reviewer found that as per the medical literature and the submitted information by the patients provider, Ocrevus is a medication that has been shown as beneficial for treatment of relapsing remitting multiple sclerosis. However, the record shows that this patient only has a history of taking the medication Copaxone for disease modification since 1999. As such, there may be other multiple sclerosis medications that may be as clinically effective as Ocrevus. An alternate medication, fingolimod, has been shown as beneficial in treating relapsing remitting multiple sclerosis.  The documentation provided does not show that this patient has had an adequate trial and failure of fingolimod. While this patient has a history of hypertension, it is not a contraindication to the medication fingolimod.  Additionally, fingolimods prescribing parameters include close monitoring of medication administration, especially with the first dose, to mitigate any potential adverse effects.  Moreover, Ocrevus also has significant side effects including increased risk of certain types of cancer.  The provider states a concern that the patient is positive for the John Cunningham virus. However, there is also the possibility that this patient may develop progressive multifocal leukoencephalopathy or PML with Ocrevus, as it is an immunosuppressant.  In general, all multiple sclerosis disease modifying medications have clinical implications or side effect profiles. In this patients case, the documentation provided does not show an adequate trial or contraindication to the preferred medication fingolimod. Fingolimod could be a reasonable option with the appropriate clinical evaluation, management, and support for this patient.  In sum, the requested medication, Ocrevus injection 300/10 mL is not medically necessary for treatment of this patients medical condition. 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 Overturned

Summary Reviewer 1

A 57-year-old male enrollee has requested authorization and coverage for the Inspire hypoglossal nerve stimulation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea.  The physician reviewer found that the medical data submitted for this case has been critically reviewed and documents a history of longstanding obstructive sleep apnea syndrome. The patient has failed to improve despite surgical interventions including standard therapy such as UPPP, hyoid suspension, genioglossus advancement and oral mandibular advancement prostheses. The patients symptomatology and polysomnogram results continue to show that the patient has fairly severe obstructive sleep apnea with apnea/hypopnea index greater than 42 episodes per hour sleep. In addition, the patient has become totally intolerant of the use of CPAP with full face mask and other masks because of the high pressures involved. Thus, the records indicate that this patient meets the clinical criteria of alternative therapy of implantation of a hypoglossal nerve stimulator (Certal, et al). Soose and colleagues reported that in patients with moderate to severe obstructive sleep apnea and a body mass index of 32 or less, hypoglossal cranial nerve stimulation therapy can provide significant improvement in important sleep related quality-of-life outcome measures and the effect is maintained across a two-year follow-up period. Given these findings, the requested Inspire hypoglossal nerve stimulation therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined 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 Overturned

Summary Reviewer 2

A 57-year-old male enrollee has requested authorization and coverage for the Inspire hypoglossal nerve stimulation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea.  The physician reviewer found that this patient has severe sleep apnea with a low oxygen nadir. He has been treated with all available standard therapies including multilevel surgery, CPAP, BiPAP, and oral appliances. Evaluation with a sleep endoscopy showed he has pathology in the area which would most benefit from hypoglossal stimulation. The hypoglossal stimulation device for the treatment of obstructive sleep apnea has been proven to be safe, and effective in clinical studies (Certal, et al; Woodson, et al). This patient is a good candidate for the recommended treatment and he has exhausted all standard alternatives. Thus, the requested Inspire hypoglossal nerve stimulation therapy is likely to be more beneficial for treatment of the patients medical condition than any standard therapy. Based upon the information set forth above, I have determined 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 Overturned

Summary Reviewer 3


A 57-year-old male enrollee has requested authorization and coverage for the Inspire hypoglossal nerve stimulation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea.  The physician reviewer found that CPAP is a first-line approach in treating OSA and has been proven to be effective with compliance. This patient has been documented to no longer be able to tolerate CPAP and the high pressures necessary to effectuate an adequate result. Traditional upper airway surgery targets the anatomic components of obstruction, but was not effective in this patient. Upper airway stimulation has been shown to improve anatomic and neuromuscular pathology in this clinical setting. A large multicenter, prospective trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. Because this patient with severe OSA has failed standard medical and surgical treatments, the requested Inspire hypoglossal nerve stimulation is likely to provide him with a superior health outcome when compared to standard available therapies. Based upon the information set forth above, I have determined 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a 12-year-old male enrollee has requested reimbursement for neuropsychological testing performed on 1/18/17. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees behavioral health issues. The physician reviewer found that Neuropsychological testing was recommended in this case to aid with determining the patients diagnosis and clarifying depression. Per the American Psychiatric Association (APA), psychological and neuropsychological tests are not mandatory for the diagnosis of ADHD, but should be performed if the patients history suggests low general cognitive ability. The current standard of care for diagnosis of ADHD is through full clinical evaluation. In addition, Wolraich and colleagues noted that to make a diagnosis of ADHD, the primary care clinician should determine that Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria have been met. This patients records do not indicate that the patient had a low general cognitive ability or any other neurological deficits that would require further and more complex evaluation. This patient had a history of tics and memory problems. Tics are more common in children with anxiety and ADHD but do not necessitate any form of neuropsychological testing. The patients memory problems can be explained by a diagnosis of ADHD. The criteria listed in the patients intake assessment are consistent with the diagnostic criteria for ADHD and additional testing was therefore not indicated. In summary, the neuropsychological testing performed on 1/18/17 was not medically necessary for evaluation of this patients medical condition. Based on the foregoing, the testing at issue was not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 52-year-old male enrollee has requested authorization and coverage for bronchoscopic thermoplasty. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. There is a lack of supporting documentation provided for review, such as the patients IgE level, eosinophil level, and allergy testing results. In addition, there is a lack of documentation demonstrating that alternative treatments such as Nucala, Xolair or lifestyle changes would be more effective. For the reasons stated, bronchoscopic thermoplasty has not been established as medically necessary for treatment of the patients medical condition.  Given the above reasons, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 
The patient is a 32-year-old female with excessive daytime sleepiness with Epworth sleepiness score of 18/24. She had a sleep study showing no obstructive sleep apnea followed by a multiple sleep latency test (MSLT) which was consistent with idiopathic hypersomnia with sleep latency less than 8 minutes, but no sleep-onset rapid eye movement (REM). The patient has requested authorization and coverage for Sunosi 75 mg tablets. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination.  The physician reviewer found that Sunosi is a new wake promoting medication that has been approved by the U.S. Food and Drug Administration (FDA) to treat narcolepsy or hypersomnia secondary to residual obstructive sleep apnea. Sunosi is a promising treatment for excessive daytime sleepiness regardless of the cause. Idiopathic hypersomnia is a rare condition. Thus, there is a lack of studies evaluating the effects of Sunosi for the treatment of idiopathic hypersomnia. Sunosi is not contraindicated for idiopathic hypersomnia. Idiopathic hypersomnia shares the same symptoms with narcolepsy type 2, except MSLT shows no sleep-onset REM, which is a narcolepsy characteristic. The requested medication is likely to be as effective for the treatment of idiopathic hypersomnia as treating excessive daytime sleepiness secondary to narcolepsy or obstructive sleep apnea. This patient failed first-line treatment, which is modafinil, and responded to Sunosi 75 mg. There is support for the requested medication in this clinical setting. Therefore, Sunosi 75 mg tablets are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 65-year-old male enrollee has requested authorization and coverage for Botox injections. 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 the current medical evidence supports the requested services in this clinical setting. There are many therapeutic uses of Botox injections. In muscle tension dysphonia or spasmodic dysphonia, the muscles of the vocal cords are in spasm, and this impacts the voice. Injection of botulinum toxin weakens the muscles to normalize the voice. This therapy has been used successfully in many patients for decades. The typical duration of action is three to four months. Botox injections are a safe and effective primary therapy for spasmodic dysphonia. Therefore, Botox injections are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 40-year-old female enrollee has requested reimbursement for the Decision Dx test and specimen handling provided on 11/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the Decision Dx melanoma diagnostic test has not been demonstrated in the peer-reviewed medical literature to improve health outcomes when compared with standard testing and evaluation. In addition, there is a lack of data to support using immunotherapy in patients with Stage I disease regardless of recurrence risk. All told, the Decision Dx test and specimen handling provided on 11/23/15 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 services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


A 40-year-old female enrollee has requested reimbursement for the Decision Dx test and specimen handling provided on 11/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but suggest a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha (Balch, et al). There is a paucity of data on the Decision Dx test to be incorporated into the treatment algorithm beyond standard staging techniques. Accordingly, the Decision Dx test and specimen handling provided on 11/23/15 were 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 services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 40-year-old female enrollee has requested reimbursement for the Decision Dx test and specimen handling provided on 11/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by the staging system discussed by Balch and colleagues. Based on this study, a pT1a melanoma has an extremely good prognosis with a very low risk of recurrence. Decision Dx is the study of 31 genes in the melanoma cells and classifies the melanoma as Class 1, with a disease free state of 97% at five years, or Class 2, with a 31% disease free rate at five years. However, it has not been established in the scientific data that the Decision Dx findings can be used reliably to influence decision making in clinical practice. All told, the Decision Dx test and specimen handling provided on 11/23/15 were 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 services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 38-year-old female enrollee has requested authorization and coverage for Tymlos. The Heath Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that pregnancy affects bone turnover and mass significantly, but pregnancy-associated osteoporosis is a rare and heterogeneous condition. In a premenopausal woman with osteoporosis, bone mass may be improved by sufficient intake of calcium and vitamin D in addition to increased physical activity. In patients who require pharmacological treatment, teriparatide is the best treatment. The half-life of teriparatide is an hour, which is much shorter than that of bisphosphonates, making it safe for fertile women. Teriparatide can be a therapeutic option for the treatment of pregnancy-associated osteoporosis. There are pharmacological therapy modalities that can be used in pregnancy and lactation induced osteoporosis. Bisphosphonates are effective, but there are some concerns that they accumulate in bone and may expose fetus in subsequent pregnancies. Tymlos is a human parathyroid hormone related peptide analog indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture. Tymlos is not indicated for use in females of reproductive potential. There is a lack of human data regarding Tymlos use in pregnant women to inform drug associated risks. There is a paucity of data on the use of Tymlos in premenopausal women or pregnancy induced osteoporosis. There are articles and case studies reporting successful use of teriparatide in cases of premenopausal pregnancy induced osteoporosis in women who wish to consider additional pregnancies, like in this case. The records do not indicate why the decision was made to change from teriparatide to Tymlos. Therefore, Tymlos (abaloparatide) is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 64-year-old female enrollee has requested authorization and coverage for Harvoni for 24 weeks. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found Harvoni for 24 weeks is medically necessary for treatment of the patients medical condition. In the ION-2 study, 440 HCV patients underwent randomization and were treated, 20% had cirrhosis and 79% had HCV genotype 1a infection. The rates of sustained virologic response were high in all treatment groups. There was a 99% (95% confidence interval (CI), (95 to 100) in the group that received 24 weeks of ledipasvir-sofosbuvir and 99% (95% CI, 95 to 100) in the group that received 24 weeks of ledipasvir-sofosbuvir and ribavirin (Afdhal, et al). The results of an abstract were presented at the American Association for the Study of Liver Diseases Liver Meeting. In this double-blind study, Bourliere and colleagues randomized 155 patients previously unable to achieve SVR after sequential treatment with a peginterferon and ribavirin regimen followed by a protease-inhibitor (PI), peginterferon  and ribavirin regimen, to undergo treatment with ledipasvir/sofosbuvir and ribavirin placebo for 24 weeks or matching placebo for 12 weeks, followed by ledipasvir/sofosbuvir and ribavirin for 12 weeks. Patients were stratified by HCV subtype and their responses to their most recent therapy. Of the 77 patients treated with ledipasvir/sofosbuvir and ribavirin for 12 weeks, 4% experienced relapse; compared with 3% of the 77 patients treated with ledipasvir/sofosbuvir for 24 weeks, for a 3% total incidence of relapse. Based on the peer-reviewed literature, Harvoni for 24 weeks is medically necessary in this clinical setting. For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.