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

Summary Reviewer 2

A 52-year-old female enrollee has requested reimbursement for colorectal cancer screening; stool-based DNA and fecal occult hemoglobin performed on 9/16/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the Conventional assessment of colorectal cancer (CRC) risk largely involves detection of non-dysplastic adenomatous polyps. The efficacy of computed tomography (CT) colonography, of the Cologuard assay, and of detection of occult blood in stool is traditionally compared against the gold standard optical colonoscopy. Cologuard is a stool DNA test that includes molecular assays for DNA mutation and methylation biomarkers (KRAS mutations, NDRG4, and BMP3 methylation) and a non-DNA immunochemical assay for human hemoglobin. However, Cologuard and ColonSentry demonstrate inadequate sensitivity to detect precancerous lesions which is the point of colon cancer screening. Despite that the patients migraines with conventional testing, the stool-based DNA and fecal occult hemoglobin performed 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 Overturned

Summary Reviewer 3


A 52-year-old female enrollee has requested reimbursement for colorectal cancer screening; stool-based DNA and fecal occult hemoglobin performed on 9/16/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the stool-based DNA and fecal occult hemoglobin performed on 9/16/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Cologuard test analyzes stool DNA, amplifies DNA for mutational testing, and tests for stool hemoglobin. The test showed 92.3% sensitivity for colonoscopy-confirmed cancer (Imperiale, et al). In addition, these data induced the U.S. Food and Drug Administration (FDA) to approve the test for use (Patman). In this clinical setting, Cologuard 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 services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 24-year-old male enrollee has requested reimbursement for substance use residential treatment center services from 1/21/16 through 2/4/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. Upon admission, the patient was experiencing mild post-acute withdrawal symptoms.  By 1/21/16, he was not a danger to himself or others. He was medically and psychiatrically stable. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant residential level of care. He was motivated as evidenced by his active engagement in all aspects of his treatment. The patient was working on relapse prevention and completion of assignments. He was developing insight and coping mechanisms. He was on anti-craving medication.  No new problems had arisen and there was no evidence to indicate that returning him to his environment would lead to destabilization. His family was supportive and participating in his recovery.  Although he continued to struggle with his desire to drink and use, further treatment to further solidify coping skills did not require the structured environment of a residential setting. By 1/21/16, he could have been stepped down to a lower level of care. As such, the residential treatment center services from 1/21/16 through 2/4/16 were not medically necessary. Therefore, for the reasons stated above, 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 Overturned

Summary Reviewer 1

A 49-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 3/15/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who underwent a breast screening evaluation. The physician reviewer found that breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in patients with dense tissue such as this patient. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and overall increase in diagnostic accuracy compared to two-dimensional imaging alone. The medical evidence supports the service at issue in this clinical setting. All told, breast tomosynthesis performed on 3/15/17 was likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the service 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 Overturned

Summary Reviewer 2

A 49-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 3/15/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who underwent a breast screening evaluation.The physician reviewer found that digital mammography screening has been proven to decrease mortality related to breast cancer. Standard two-dimensional mammography does have significant limitations, namely obscuration of cancers within areas of overlapping or dense tissue, as well as false positive recalls due to overlapping breast tissue, which must be confirmed with additional imaging. Digital breast tomosynthesis addresses both of these issues. The addition of breast tomosynthesis decreases the false positive recall rate by allowing the radiologist to scan through slices of breast tissue rather than seeing the breast tissue superimposed on itself. This technology is especially beneficial in patients with dense breast tissue. As digital breast tomosynthesis has been proven to increase cancer detection in the screening setting, breast tomosynthesis performed on 3/15/17 was likely to have been superior over other modalities for evaluating this patient. Based upon the information set forth above, the service 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 Overturned

Summary Reviewer 3

A 49-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 3/15/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who underwent a breast screening evaluation. The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts. In very recent years, there have been several studies that have supported the use of breast tomosynthesis as a more accurate study than routine screening mammography. As noted by Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Friedewald and colleagues noted the addition of tomosynthesis to digital mammography was associated with a decrease in recall rate and an increase in cancer detection rate. In this case, this patients breasts have been described as heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures better enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis performed on 3/15/17 was likely to have been more effective than other methods of evaluating this patient.  Based upon the information set forth above, the service 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 Overturned

Summary Reviewer 1


A 57-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 11/24/15.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  Based upon the information set forth above, the service 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 Overturned

Summary Reviewer 2


A 57-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 11/24/15.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that the medical literature supports the service at issue in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  In sum, breast tomosynthesis performed on 11/24/15 was likely to have been more effective than other methods of evaluating this patient.  Based upon the information set forth above, the service 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 Overturned

Summary Reviewer 3


A 57-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 11/24/15.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breast tissue was extremely dense.  While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis performed on 11/24/15 was likely to have been superior over other methods of evaluating this patient.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 62-year-old female has requested reimbursement for brain MRI and chest x-ray performed on 3/11/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that regarding the patients headaches and vertigo, the patient had an MRI of the brain in 2015 and CT scan in February 2019, which demonstrated similar, nonspecific findings. The office notes indicate that the patients headaches had increased in frequency over the past two years. According to the American College of Radiology (ACR) appropriateness criteria, MRI of the brain without or with contrast is considered usually appropriate in the setting of increased frequency, severity or change in character of headaches. However, MRI is not indicated for evaluation of uncomplicated vertigo. Regarding the patients respiratory symptoms, the patient reported increased recent dyspnea on exertion. According to the ACR appropriateness criteria, chest radiographs are considered usually appropriate as an initial imaging study for evaluation of non-cardiovascular dyspnea. The radiographs can detect chronic or acute findings and guide the possible need for additional imaging studies. Therefore, the services at issue were medically indicated for evaluation of the patients increasing dyspnea and increasing chronic headaches. Thus, MRI of the brain and chest x-ray performed on 3/11/19 were medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 60-year-old female enrollee has requested authorization and coverage for Xifaxan 500 mg. 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 patient had small intestinal bacterial overgrowth. Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. The medication has been shown to have greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones. Results are sustained for several weeks after treatment. Moraru and colleagues performed a prospective trial of patients with irritable bowel syndrome and small intestinal bacterial overgrowth. The authors found that 86% responded to Xifaxan, and symptoms were reduced as well. Xifaxan is effective for the treatment of constipation-predominant irritable bowel syndrome. In this case, while antispasmodic medications may address irritable bowel syndrome, they would not be expected to improve small intestinal bacterial overgrowth. Anti-diarrheal medications would not be appropriate in the use of constipation. Therefore, the use of Xifaxan 550 mg three times daily for 14 days is supported as medically necessary for the treatment of this patients small intestinal bacterial overgrowth in the setting of irritable bowel syndrome.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 22-year-old male has requested reimbursement for Prometheus Anser IFX testing performed on 8/30/15.  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 there is sufficient support for the services at issue in this clinical setting.  With respect to maintenance of healing of perianal disease in Crohns disease, Remicade has the strongest evidence to support its use.  Therefore, it is critical to identify whether the patient is developing antibodies or a sub-therapeutic levels of infliximab as discontinuation or an increase in dose may be necessary depending on the results.  In sum, Prometheus Anser IFX testing performed on 8/30/15 was likely to have been superior over other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were 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


A 22-year-old male has requested reimbursement for Prometheus Anser IFX testing performed on 8/30/15.  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 submitted records fail to demonstrate the superior effectiveness of the services at issue.  Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment.  The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  However, there are few well-controlled clinical trials to confirm that use of the Anser IFX testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  Therefore, Prometheus Anser IFX testing performed on 8/30/15 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 22-year-old male has requested reimbursement for Prometheus Anser IFX testing performed on 8/30/15.  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 Prometheus Anser IFX test was ordered to direct the use of Remicade (infliximab) in this patient with Crohns disease. However, the use of the testing at issue to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold levels been established. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. Therefore, it is unclear whether dosage should be increased, the medication should be changed, or another course of action should be taken.  Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing.  Thus, Prometheus Anser IFX testing performed on 8/30/15 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 63-year-old female enrollee has requested reimbursement for FoundationOne CDx testing performed on 11/27/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition.  The physician reviewer found that this patient was diagnosed with endometrial cancer. The patient had a hysterectomy and salpingo-oophorectomy and the final pathology showed an endometrial adenocarcinoma. A portion of the tumor tissue was submitted for FoundationOne CDX testing. The test performed microsatellite assessment, tumor mutational burden, as well as an analysis of mutations in over 400 known tumor suppressor and oncogenes. Endometrial cancers have been analyzed in depth, and the current pathology work-up recommends detailed molecular analysis. The current medical evidence supports the services at issue in this clinical setting. Therefore, FoundationOne CDx testing performed on 11/27/20 was likely to have been more beneficial than other available standard therapy.