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

Summary Reviewer 2

A 32-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 9/24/19. 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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index adds a bit to these statistics. DecisionDx-Melanoma testing is a 31-gene assay of the genomic-molecular abnormalities within an individualas melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not known if the DecisionDx-Melanoma classification can be used to make clinical decisions. The decision about whether or not to do a sentinel node is based on thickness and other pathologic features, not DecisionDx-Melanoma classification. The decision about adjuvant therapy is generally based on the results of the sentinel node biopsy, if performed, and other pathologic features. The National Comprehensive Cancer Network does not recommend the use of the DecisionDx-Melanoma assay to make clinical decisions. Therefore, DecisionDx-Melanoma testing performed on 9/24/19 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 32-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 9/24/19. 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 Melanoma is a cancer that is curable in its earliest stages. 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 this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. This is also the consensus opinion of the National Comprehensive Cancer Network. Therefore, DecisionDx-Melanoma testing performed on 9/24/19 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 16-year-old transgender male enrollee has requested reimbursement for bilateral mastectomy performed on 6/20/18. The Health Insurer has denied this request indicating that the procedure at issue was not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found that the submitted documentation supports the medical necessity of the procedure at issue. This patient had a mental health assessment from a qualified mental health provider. He meets World Professional Association for Transgender Health (WPATH) criteria for chest surgery as a medically necessary treatment for gender dysphoria. The patients age being under 18 does not affect the medical necessity of the procedure. WPATH states that chest surgery for transgender male adolescents may be done under 18. One year of hormone treatment and social transition is suggested, but not required. Per the records, this patient had met these suggestions for hormone treatment and social transition. The current medical evidence supports the procedure at issue in this clinical setting. Thus, bilateral mastectomy performed on 6/20/18 was medically necessary for the treatment of this patient. Therefore, the procedure at issue was 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 57-year-old female enrollee has requested reimbursement for testing for cancer risk using panels of genes (MyRisk) provided on 6/05/19. 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 the submitted documentation supports the superior efficacy of a portion of the services at issue. Given that the patients mother developed breast cancer at age 36, she does fall within guidelines for BRCA testing. However, this patient was evaluated with the MyRisk panel, which is a 25 gene panel including BRCA. Although there is great interest in the other genes, there is little data to support making clinical decisions on the basis of the other genes alone. Even in families with a strong history, such as this one, it is not clear that the other genes significantly add to the risk profile beyond what the family history alone provides. Therefore, the BRCA portion of the testing was likely to have been more beneficial than other methods of evaluating this patient. However, the superior effectiveness of the remaining tests has not been established.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 57-year-old female enrollee has requested reimbursement for testing for cancer risk using panels of genes (MyRisk) provided on 6/05/19. 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 an individuals personal and/or family history may be explained by more than one inherited cancer syndrome. Thus, phenotype-directed testing based on personal and family history through a multigene panel test may be more efficient and increase the yield of detecting a pathogenic/likely pathogenic variant in a gene that will impact medical management for the patient or at-risk family members. The largest studies reporting on the outcomes of multigene testing indicate that among women tested in clinical settings, about 5 to 10 percent have a BRCA1 or BRCA2 mutation, and about 4 to 7 percent have a harmful mutation in another gene associated with high to moderate
risks of breast and/or ovarian cancer, or a mutation in a newer gene that may also be associated with increased risks for these cancers. Panel testing, such as with MyRisk, is now considered a standard of care in patients at high risk to carry a genetic mutation, such as this patient. All told, testing for cancer risk using panels of genes (MyRisk) provided on 6/05/19 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 57-year-old female enrollee has requested reimbursement for testing for cancer risk using panels of genes (MyRisk) provided on 6/05/19. 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 this patients family history is suggestive of a breast/ovarian cancer syndrome. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gallbladder, bile duct, prostate, pancreatic, and gastric cancers. In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. There are guidelines in place that evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer tumors in families. The most common extracolonic cancer in Lynch syndrome is endometrial cancer followed, in no particular order, by ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral. The MyRisk panel is appropriate since the current clinical situation may be caused by several potential cancer-causing genes. Thus, testing for cancer risk using panels of genes (MyRisk) provided on 6/05/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a 17-year-old male enrollee has requested reimbursement for residential treatment provided from 2/06/13 through 5/03/13. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  In this case, the patient was struggling with the developmental stage of identity formation which was complicated by a formidable anxiety and affective burden coupled with an underdeveloped sense of self and substance use which fueled dysphoria and parent-child disharmony.  The documentation provided does not support the medical necessity of the services at issue during the disputed timeframe.  It appears as though the patient and his family had not pursued evidence-based treatments in a less restrictive setting during the episode of illness.  Such interventions include, but are not limited to, school-based services, psychotherapy, chemical dependency counseling, family therapy, parent training and pharmacotherapy.  Additionally, the medical records did not include a psychiatric evaluation, psychosocial assessment, history and physical examination, or integrated summary justifying the necessity of the placement as opposed to a lower level of care.  The discharge summary, psychological evaluation and initial treatment plan did not describe behaviors, symptomatologies, or treatment interventions that would typically require a 24-hour supervised setting.  In sum, the documentation submitted for review did not suggest that a less restrictive setting would have been insufficient.  All told, residential treatment provided from 2/06/13 through 5/03/13 was not medically necessary for the treatment of this patient.  Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 41-year-old male enrollee has requested reimbursement for intravenous immunoglobulin provided from 4/24/15 through 5/01/15 and 8/07/15 through 8/14/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the efficacy of intravenous immunoglobulin has been proven in Guillain-Barre syndrome, chronic inflammatory demyelinating polyradiculoneuropathy, multifocal mononeuropathy, acute exacerbations of myasthenia gravis, short-term treatment of severe myasthenia gravis, and some paraneoplastic neuropathies.  This patient has been diagnosed with polyneuropathy.  Clinical examination does not describe neuropathy features such as distal weakness or reflex loss. Nerve conduction velocities were mildly slowed, consistent with demyelination, but there was no evidence of conduction block reported.  There was no distal latency prolongation, increased temporal dispersion, or delayed or absent F waves reported.  Per the submitted documentation, this patient does not meet published criteria for CIDP, which indicate that the diagnosis rests upon a combination of clinical, electrodiagnostic and laboratory features with exclusions to eliminate other disorders that may appear as CIDP.  There is a lack of support for the services at issue in this clinical setting.  All told, intravenous immunoglobulin provided from 4/24/15 through 5/01/15 and 8/07/15 through 8/14/15 was not medically indicated for the treatment of this patient.  Therefore, the services at issue were 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 


A 64-year-old female enrollee has requested authorization and coverage for Kadian 50 mg three times per day. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees neck and bilateral shoulder pain. The physician reviewer found that in this case, the request for Kadian 50 mg three times per day is medically necessary and reasonable for management of this patients medical condition. The patient has post-laminectomy syndrome with ongoing chronic pain. The patient previously had an intrathecal pain pump which was removed secondary to meningitis. The patient has been maintained on Kadian 50 mg three times per day for over 10 years with appropriate monitoring and safeguards in place. The records document that Kadian 50 mg three times per day keeps her active and allows her to participate in her activities of daily living. All told, the requested Kadian 50 mg three times per day is supported as medically necessary for treatment of this patients medical condition. Based on the foregoing, the requested medication is 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 64-year-old female enrollee has requested reimbursement for collagen crosslinks testing performed on 11/18/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees osteoporosis. The physician reviewer found that Osteoporosis is a condition of thinning of the bones which leads to increased risk of fracture. Bone mineral density (BMD) assessment, via dual-energy x-ray absorptiometry (DEXA) is the standard for evaluation and diagnosis of osteoporosis.  However, because changes in bone mass and density in response to antiresorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover may be a useful adjunct in monitoring of osteoporotic patients treated with antiresorptive agents. The medical evidence suggests that biochemical markers may be useful in making therapeutic decisions because, in general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine. The medical evidence supports the services at issue in this clinical setting. Therefore, collagen crosslinks testing performed on 11/18/17 was 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 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 64-year-old female enrollee has requested reimbursement for collagen crosslinks testing performed on 11/18/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees osteoporosis. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue. This patient has been taking Tymlos. In this clinical setting, a dual-energy x-ray absorptiometry (DEXA) is appropriate at the end of the two-year treatment to assess the patients response to therapy. The value of monitoring therapy with the use of biochemical markers of bone turnover to aid in clinical decision making is controversial. The test performed can be variable and subject to timing, dietary intake as well as lack of assay standardization. In sum, collagen crosslinks testing performed on 11/18/17 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 3

A 64-year-old female enrollee has requested reimbursement for collagen crosslinks testing performed on 11/18/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees osteoporosis. The physician reviewer found that Biochemical markers provide a dynamic view of the remodeling process, which covers rate of turnover and pathogenesis, and should improve fracture risk prediction. Furthermore, biochemical markers can be used to monitor the short-term effects of therapy, and indicate if an excessive slowing of the remodeling process is occurring. Suppression of biochemical markers of bone turnover after three to six months of treatment and biochemical marker increases after one to three months of anabolic therapy have been predictive of greater bone mineral density responses and fracture risk reduction in large clinical trials. In this case, the patient had recently started a new anabolic agent. The information derived from collagen crosslinks can be used to determine whether the therapy is working and whether the patient is compliant with therapy. Thus, collagen crosslinks testing performed on 11/18/17 was likely to have been more effective than 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 



A 57-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 6/24/16. The Health Plan has denied this request indicating that the service at issue was not medically necessary for evaluation of the enrollees breast examination. The physician reviewer found that the tomosynthesis often allows the radiologist to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional (2D) imaging alone. The American College of Radiology (ACR) considers 2D mammography as medically necessary for the screening of breast cancer, and considers the addition of tomosynthesis to be of added value for patients with dense breast tissue. Although breast tomosynthesis has become widely accepted in the breast imaging arena, breast tomosynthesis performed on 6/24/16 is not considered medically necessary for evaluation of the patients medical condition.  Therefore, the service 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 Overturned

Summary Reviewer 


A 45-year-old male enrollee has requested authorization and coverage for Harvoni.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.  Therefore, the requested medication is 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 68-year-old male enrollee has requested reimbursement for the positron emission tomography (PET) scan performed on 2/3/15. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for evaluation of the enrollees cognitive impairments, neuropsychiatric symptoms and parkinsonian features.  The physician reviewer found that the PET scan performed on 2/3/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. PET is a standard procedure performed by providers when dementia is atypical, and most specifically to differentiate Alzheimers disease from frontotemporal dementia. This diagnostic procedure allows the patient and his family to better understand prognosis and treatment, and guide the treating provider to provide the best treatment. In this case, MRI showed nonspecific atrophy. The EEG showed spike and slow wave discharges suggesting epilepsy. In addition, neuropsychology testing suggested frontotemporal dementia, and the examination showed Parkinsonian features. The patient presented with a subacute onset of progressive memory problems. In this complex clinical setting, the diagnostic procedure at issue 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 diagnostic procedure 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.