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

Summary Reviewer 

A 31-year-old female enrollee has requested authorization and coverage for Uceris 2 mg rectal foam. The Health 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 the submitted documentation supports the requested medication in this clinically setting. This patient has left-sided ulcerative colitis based on colonoscopy and recent computed tomography scan. Budesonide foam primarily works in the rectum and left colon. American College of Gastroenterology guidelines for the treatment of ulcerative colitis state that colonic delivery of budesonide offers more directed therapy and fewer systemic side effects than alternatives (given the high first-pass hepatic metabolism of budesonide), and that in patients with moderately active ulcerative colitis, non-systemic corticosteroids such as budesonide should be considered before the use of systemic therapy. The guidelines also recommend the use of topical rectal therapy before systemic therapy in distal colitis. Studies of budesonide foam have shown minimal systemic adverse effects, and that budesonide foam is well-tolerated and effective. A double-blind randomized trial by Naganuma and colleagues demonstrated effectiveness of budesonide foam in distal ulcerative colitis. Budesonide foam is supported as safe and effective for the treatment of distal colitis. Therefore, Uceris 2 mg rectal foam is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The patient is a 66-year-old male with a history of lower extremity swelling, hypertension, coronary artery disease, and hyperlipidemia. A lower extremity venous mapping ultrasound on 6/13/17 demonstrated no evidence of deep vein thrombosis (DVT). The bilateral greater saphenous veins were ablated. The right short saphenous vein was 4.2 mm with four seconds of reflux. A right medial distal calf perforator was noted with reflux. The left short saphenous vein was 7.5 mm with three seconds of reflux. There was a left medial distal calf perforator noted with reflux. Based on these results, the plan was for radiofrequency ablation (RFA) of bilateral short saphenous veins with RFA of bilateral medial distal calf perforators and ultrasound-guided sclerotherapy of varicose vein tributaries. The patient was treated with compression stockings. On 8/11/17, the provider noted the patient reports leg pains, achiness in the legs, night cramps, restless legs, leg swelling, and chronic skin color changes. The patients symptoms are interfering with his ability to perform activities of daily living. On physical examination, no clubbing or cyanosis is noted. There is bilateral ankle edema, left greater than right. The patient has requested authorization and coverage for endovenous vein ablation. The Health Insurer has denied this request indicating that the requested services are considered investigational. The documentation does not demonstrate that this patients current symptoms are due to his short saphenous vein reflux. The patient has not been reevaluated since he was treated with compression stockings and there is no documentation that he has been using them regularly. Moreover, there is no documentation of adequate lower extremity arterial perfusion in this patient with a history of coronary artery disease, hyperlipidemia, hypertension, and leg pain. Given these findings, the requested endovenous vein ablation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the 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 2

The patient is a 66-year-old male with a history of leg achiness, tightness, swelling, skin discoloration and heaviness for five years. His body mass index (BMI) is 39. The patient is documented as having worn compression stockings for more than five months without perceived benefit. An ultrasound report noted reflux in the bilateral short saphenous vein (SSV) and reflux in the bilateral medial distal calf perforator veins. The bilateral greater saphenous vein were noted to have been ablated. There was no evidence of deep vein thrombosis (DVT). The provider recommended radiofrequency ablation of bilateral SSV and bilateral medial distal calf perforator veins as well as ultrasound guided injections of varicose vein tributaries. The patient has requested authorization and coverage for endovenous vein ablation. The Health Insurer has denied this request indicating that the requested services are considered investigational. Consensus indications for radiofrequency ablation include venous diameter within 2-20 mm, reflux time of 0.5 or more seconds, and distance from the skin 5 or more mm, or subfascial location. There are insufficient level 1 or level 2 studies in the literature to demonstrate that radiofrequency ablation of perforators is appropriate and a lack of evidence to support perforator surgery in the absence of stage 5 and 6 chronic venous disease. Overall, the current guidelines do not support the requested endovenous vein ablation for treatment of this patients medical condition.  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


The patient is a 66-year-old male with history of bilateral greater saphenous vein (GSV) ablations. Despite the continued use of medical grade compression stockings for more than five months, he remains symptomatic with tired, heavy, achy legs and associated skin changes. He has no active skin ulcers. Ultrasound on 6/13/17 demonstrated prior bilateral GSV ablations, pathologic reflux in both short saphenous veins and refluxing tributaries, and pathologic reflux in both calf perforator veins. The patient has requested authorization and coverage for endovenous vein ablation. The Health Insurer has denied this request indicating that the requested services are considered investigational. The patient meets the criteria for the ablation of the short saphenous vein and the ultrasound guided sclerotherapy. The current medical literature indicates that the recommended size for ablation is 4.5 mm. This patients left small saphenous vein is 7.5 mm with pathologic reflux, and the right small saphenous vein is 4.2 mm with pathologic reflux. Ultrasound guided sclerotherapy is appropriate for the tributaries on the basis of size and reflux criteria, after the small saphenous veins are ablated. However, there is a lack of peer-reviewed literature supporting better outcomes with ablations of refluxing perforators compared to other therapies. These can be treated by ultrasound guided sclerotherapy, after the short saphenous vein ablations. Thus, the small saphenous vein ablations are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy while the perforator ablations are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, a portion of 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 partially overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 41-year-old female enrollee has requested reimbursement for Cymetra micronized AlloDerm tissue provided on 2/13/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees left vocal fold paresis status post excision of vagal nerve schwannoma.  The physician reviewer found there are many different types of injectable material used for augmentation of a paralyzed vocal cord. Cymetra micronized AlloDerm injectable tissue is a widely utilized material for use in this clinical setting. It has low risk of infectious transmission, but is otherwise medically indicated and accepted as part of standard care in the otolaryngologic community. All told, the Cymetra micronized AlloDerm tissue provided on 2/13/15 was medically necessary for treatment of this patients left vagal nerve schwannoma with resultant left vocal cord paresis. In conclusion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 41-year-old male who has been diagnosed with relapsing remitting multiple sclerosis. He was diagnosed in 2014 after an episode of optic neuritis and left leg tingling and was started on disease-modifying therapy (DMT) with Copaxone. The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting. The American Academy of Neurology issued practice guideline recommendations for disease-modifying therapies (DMTs) for adults with multiple sclerosis. As noted by Rae-Grant and colleagues, respecting patient preferences is an important component of care for chronic conditions. Because of the variety of DMTs available, evaluating patient preferences may improve acceptance of and adherence to DMT. The authors noted Because DMT requires adherence to
treatment to provide full efficacy, and because that adherence to treatment may be an issue for people with multiple sclerosis, discussing adherence issues before initiating DMT is part of good clinical practice. Efforts to increase adherence may improve outcomes. A systematic review by McCool and colleagues compared ocrelizumab with other disease-modifying treatments for relapsing multiple sclerosis. Per the authors, Results suggest that ocrelizumab has superior efficacy to 10 of the 17 treatments in the 12-week confirmed disability progression network and 12 of the 17 treatments in the annualized relapse rate network (both including placebo). The efficacy of ocrelizumab was comparable with the other treatments in both networks. In the serious adverse events and discontinuation due to adverse events networks, ocrelizumab demonstrated a safety profile comparable with all other treatments (including placebo). In this case, the patient has a diagnosis of relapsing remitting multiple sclerosis presenting with a recent relapse and active lesions on MRI. He was on DMT with Copaxone but had difficulty with compliance. The provider presented and weighed the options for DMT and determined that Ocrevus to be the best in terms of safety and compliance for the patient. Further, the results of studies as shown above suggest that ocrelizumab has an efficacy superior to or comparable with other currently approved DMTs. Therefore, ocrelizumab (Ocrevus) 300 mg 1 day and 15 day is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 59-year-old male enrollee has requested reimbursement for gene testing performed on 9/13/16. The Health Insurer has denied this request indicating that the requested services were not medically necessary for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of clinical trials. There is lack of evidence as to its efficacy and how the results would change treatment recommendations, such as in this case. Accordingly, the services at issue are not considered to be standard of care in this clinical setting. Therefore, gene testing performed on 9/13/16 was not medically necessary for the evaluation of this patients medical condition. Based on the information above, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 38-year-old male enrollee has requested authorization and coverage for chemotherapy administration into the peritoneal cavity via indwelling port or catheter (hyperthermic intraperitoneal chemotherapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the use of hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis for colon cancer remains controversial. It is suspected that about 25% of patients with metastatic colorectal cancer have disease limited to the peritoneal cavity and that perhaps this represents a different entity than metastatic disease involving the liver and lungs. Studies suggest a benefit from hyperthermic intraperitoneal chemotherapy in carefully selected patients.  However, standard use remains the subject of ongoing clinical trials.  At this time, there is a need for randomized clinical trials addressing the risks and benefits associated with this modality.  At this time, the use of hyperthermic intraperitoneal chemotherapy has not been shown to be superior to standard chemotherapies for colorectal cancer.  All told, the requested services are not likely to be superior over 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 2


A 38-year-old male enrollee has requested authorization and coverage for chemotherapy administration into the peritoneal cavity via indwelling port or catheter (hyperthermic intraperitoneal chemotherapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the requested services in this clinical setting.  The use of heated intraperitoneal chemotherapy for colon cancer with peritoneal carcinomatosis is not considered to be standard of care.  The current medical literature does not support the requested services in this patients case.  The National Comprehensive Cancer Network guidelines do not support hyperthermic intraperitoneal chemotherapy in this patients case.  Therefore, the requested hyperthermic intraperitoneal chemotherapy is not likely to be of greater benefit than other treatment modalities.  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 38-year-old male enrollee has requested authorization and coverage for chemotherapy administration into the peritoneal cavity via indwelling port or catheter (hyperthermic intraperitoneal chemotherapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is sufficient support for the requested services in this clinical setting.  Hyperthermic intraperitoneal chemotherapy has followed debulking surgery in many of the series that have been published with good results.  In one randomized clinical trial by Verwaal and colleagues, cytoreduction followed by hyperthermic intraperitoneal chemotherapy improved survival in peritoneal carcinomatosis of colorectal origin. The results were the same after an eight-year follow-up report.  In sum, the requested hyperthermic intraperitoneal chemotherapy is likely to be of greater benefit than 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 58-year-old female enrollee has requested reimbursement for Monovisc knee injections provided on 5/18/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees knee osteoarthritis. The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis. In addition, the benefits of hyaluronic acid are long-lasting as compared with intraarticular corticosteroids. In a systematic review of meta-analyses, Campbell and colleagues compared hyaluronic acid injections with other non-operative treatment modalities for knee osteoarthritis. The authors found that intraarticular hyaluronic acid improves knee pain and function for up to 26 weeks. Moreover, Maheu and colleagues noted that the benefits of intraarticular hyaluronic acid on knee osteoarthritis may include mechanical viscosupplementation of the joint (allowing lubrication and shock absorption) andthe re-establishment of joint homeostasis through induction of endogenous HA [hyaluronic acid] production, which continues long after the exogenous injection has left the joint. This patient has reported excellent results with prior hyaluronic acid injections. All told, the Monovisc knee injections provided on 5/18/18 were medically necessary for treatment of this patients bilateral knee osteoarthritis. Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 60-year-old male enrollee has requested reimbursement for Oncotype testing performed on 4/25/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there currently are three major approaches to the management of localized prostate cancer. These are surgical prostatectomy, forms of radiation therapies, and active surveillance, with no specific anti-cancer treatment given. The treatment recommendation is based on risk stratification, which is a methodology combining pathologic and clinical features. In this case, the patient would be classified as being in the favorable intermediate risk category, for which it is not entirely clear what recommendation should be made. The National Comprehensive Cancer Network suggests using genomic assays as an adjunct to treatment decisions in this risk category. Oncotype DX assay is a 17-gene assay that is capable of assessing risk of recurrent disease. In this patients case, adding Oncotype assay to his evaluation was likely to have been beneficial. Therefore, Oncotype DX testing performed on 4/25/19 was likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 60-year-old male enrollee has requested reimbursement for Oncotype testing performed on 4/25/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that National Comprehensive Cancer Network guidelines indicate that men with low or favorable intermediate risk disease post biopsy may consider the use of tumor-based molecular assays, such as Oncotype DX testing. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays.  It is considered a standard of care in guiding treatment decision making. In sum, Oncotype DX testing performed on 4/25/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 60-year-old male enrollee has requested reimbursement for Oncotype testing performed on 4/25/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that 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. The important features to recognize are Gleason score and prostate-specific antigen, but these are imperfect. At this time, current biomarkers are inadequate for risk stratification, and better prognostic biomarkers are needed. Oncotype DX is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score. This assay may help identify patients with low risk disease that could be followed rather than referred for surgery. Oncotype DX may better stratify such patients with localized disease. Thus, Oncotype DX testing performed on 4/25/19 was likely to have been more beneficial than other methods of evaluating this patient.