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

Summary Reviewer 

A 73-year-old male enrollee has requested reimbursement for targeted genomic sequence analysis performed on 5/30/19. 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 molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network guidelines strongly advise broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Molecular profiling was medically appropriate in this patients case. Therefore, targeted genomic sequence analysis performed on 5/30/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 61-year-old female enrollee has requested authorization and coverage for home health aide services eight (8) hours per day three (3) days per week (Monday, Wednesday, Friday). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees hemorrhagic stroke with left-sided hemiparesis. The physician reviewer found that per the reviewed literature, a providers orders for services in the plan of care must specify the medical treatments to be furnished as well as the type of home health discipline that will furnish the services and at what frequency the services will be provided. This patients documentation states that the provider noted that health aide services eight hours per day three days per week (Monday, Wednesday, Friday) are medically necessary and reasonable given the patients deficits and complex medical history. This patient has left-sided hemiparesis and sustained a fall resulting in left radial/ulnar fracture which will require surgery. She remains at risk for subsequent falls and requires assistance with all activities of daily living. Given these findings, the requested home health aide services eight (8) hours per day three (3) days per week (Monday, Wednesday, Friday) are supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested services are 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 


A 41-year-old female enrollee has requested reimbursement for MyRisk genetic testing performed on 1/24/17.  The Health Insurer has denied this request and reported that the services at issue were not medically necessary for evaluation of the enrollee, who has a family history of cancer. The physician reviewer found the submitted documentation supports the medical necessity of a portion of the services at issue.  BRCA testing guidelines recommend BRCA testing for this patient who has a close relative with ovarian cancer.  However, this patient has requested reimbursement for the MyRisk panel. This is a 25-gene panel that includes BRCA testing, but also a variety of other suspected risk genes. Although many of these other gene mutations are of interest and are being studied, for the most part, they have as yet not been found to be significant enough to be the basis for clinical decisions for the carriers or their family members. Such testing is not included in the guidelines from the major organizations.  Therefore, BRCA testing was likely to have been more effective than other methods of evaluating this patient.  However, the current medical evidence has not established the superior efficacy of the remainder of the testing performed. Therefore, a portion of the services at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 78-year-old female enrollee has requested authorization and coverage for positron emission tomography (PET) imaging and magnetic resonance imaging (MRI) of the bilateral breasts. The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested MRI of the bilateral breasts.  The literature does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound.  MRI studies of the breast are highly sensitive, but have a relatively low level of specificity.  In this particular patient, the medical evidence does not support MRI of the bilateral breasts.  The only indicator in this patient that something might be amiss is the elevated tumor marker.  While breast MRI is becoming increasingly commonplace, there is insufficient data available to support its use as a routine screening study in patients with a relatively average risk of developing breast cancer. However, there is sufficient support for the requested PET imaging in this clinical setting.  In this case, since the elevated tumor marker was identified, and the referring provider believed it was necessary to explore the possibility of recurrence, simple imaging was performed.  The CT scan and the bone scan were inconclusive.  Advanced imaging such as PET scanning may be warranted for patients in which conventional imaging is inconclusive.  If further investigation of the elevated tumor marker is felt to be clinically indicated, PET scan is appropriate.  Although the small lesions seen in the lung bases are likely too small to be metabolically active, there is some value in searching for other sites of occult tumor such as the bones.  In sum, the requested PET imaging is medically necessary.  However, the requested MRI of the bilateral breasts is not medically indicated for the evaluation of this patient.  Therefore, a portion of the requested services is medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 56-year-old male enrollee who has requested reimbursement for Oncotype DX Prostate. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that The National Comprehensive Cancer Network (NCCN) guidelines define the low-risk group as patients with clinical stage T1 to T2a, Grade Group 1, and serum prostate-specific antigen (PSA) level less than 10 ng/mL. If the patients life expectancy is 10 years or more, initial treatment options include: 1) active surveillance (preferred); 2) external beam radiotherapy or brachytherapy; or 3) radical prostatectomy. This patient meets this criteria. Molecular tumor testing can be considered for these men for prognostic information independent of NCCN risk groups. There is sufficient support for the services at issue in this clinical setting. Therefore, Oncotype DX Prostate testing performed on 9/19/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 48-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 1/20/17. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was not medically necessary for evaluation of the enrollees right breast lump and discharge from the nipple. The physician reviewer found that Tomosynthesis was approved for clinical use by the U.S. Food and Drug Administration (FDA) in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of mammography, the American College of Radiology (ACR) has urged the technique be removed from the investigational category in 2014 due to the advantage it provides radiologists interpreting mammograms especially in women with dense tissue. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortions resulting in a decrease in callbacks and increase in overall diagnostic accuracy. However, the standard of practice for radiology does not yet require tomosynthesis on all mammography cases. Thus, the use of digital breast tomosynthesis performed on 1/20/17 was not medically necessary for evaluation of this patients right breast lump and discharge. Based on the foregoing discussion, the diagnostic procedure 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

The patient is a 64-year old female with a history of hypertension, hyperlipidemia and hypothyroidisms. There is reported intolerance to generic beta blocker medication and generic losartan (Cozaar). The patient reported dizziness and headache. The patient has requested authorization and coverage for the brand medication Cozaar. The Health Insurer denied this request and reported that the requested brand medication is not medically necessary for the treatment of the patients medical condition.  This denial is the subject of this appeal and determination. There is a lack of support in the documentation provided for the medical necessity of the requested brand name medication. Based on the records provided, the patient has been diagnosed with hypertension and she reported side effects to some medications. However, the symptoms of headaches and dizziness, in the absence of hypotension, are uncommon side effects to generic losartan medication. In addition, there is a lack of temporal association between the start of the losartan and the symptom onset. The record notes that losartan was started six weeks prior to the reported dizziness and headaches making a causal relationship unlikely. The documentation provided does not demonstrate a significant intolerance to the generic losartan medication.  Moreover, there are additional formulary medications that have not been documented as trialed if a true intolerance to losartan medication were to be demonstrated. In sum, Cozaar has not been demonstrated as medically necessary for treatment of this patients medical condition. Therefore, based on the above, the requested medication is 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 

The patient is a 54-year-old female who was diagnosed with a high-grade triple negative left-sided breast cancer. The patient has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that guidelines do not endorse the routine use of proton therapy in the treatment of breast cancer. There is a lack of data to suggest that proton beam therapy would be beneficial in this case or that it would be associated with less side effects than standard treatment with photons. The standard treatment in this case would be with chemotherapy, followed by surgery, followed by radiation with photons. Furthermore, consensus group guidelines do not support the use of proton therapy in this setting. In the vast majority of cases, intensity modulated radiation or three-dimensional conformal techniques with photons is able to achieve an acceptable cardiac and lung dose. Furthermore, treatments using deep inspiratory breath hold, which move the heart away from the chest wall, are also associated with very low cardiac doses in patients receiving radiation for breast cancer. In this case, although the comparison planning shows lower heart and lung doses with the proton plan, the standard plan with photons is not representative of typical cardiac or lung doses with intensity modulation or breath hold techniques. There is a lack of level I evidence to support the use of proton therapy for the treatment of breast cancer. Therefore, the requested proton beam therapy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 61-year-old male who has requested reimbursement for Oncotype Dx Prostate Cancer Assay performed on 3/31/20.  The patient has requested reimbursement for Oncotype Dx Prostate Cancer Assay performed on 3/31/20. 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 the National Comprehensive Cancer Network (NCCN) recommends Oncotype Dx Prostate Cancer Assay post-biopsy for men with low or favorable intermediate risk disease. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of NCCN 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. This patient is considered to have low risk disease and would fit these criteria. It is considered a standard of care in guiding treatment decision making. There is sufficient support for the services at issue in this setting. Therefore, Oncotype Dx Prostate Cancer Assay performed on 3/31/20 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 66-year-old male enrollee has requested reimbursement for the unlisted chemistry procedure (84999) Prometheus Anser testing performed on 12/22/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease.  The physician reviewer found the concept of following drug levels when using tumor necrosis factor (TNF)-alpha antibodies to provide personalized dosing has been around for many years. Following drug levels can keep a patient at a target level which translates into a higher probability of clinical benefit. This concept is based primarily on retrospective data which has demonstrated that, in general, higher trough levels correlate directly, and the presence of antibody correlates indirectly, with clinical efficacy. Knowledge of the drug and antibody level would therefore assist the provider in the decision to increase a drugs dose or perhaps switch to another class of biologics. However, this approach has not been shown to be superior to making empiric changes. There is a lack of controlled data which have identified the optimal drug level. A recent trial demonstrated this approach had no impact on clinical efficacy compared to empiric dose titration (Steenholdt, et al). Therefore, the unlisted chemistry procedure (84999) Prometheus Anser testing performed on 12/22/15 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 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 2


A 66-year-old male enrollee has requested reimbursement for the unlisted chemistry procedure (84999) Prometheus Anser testing performed on 12/22/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease.  The physician reviewer found in this case, Anser testing was ordered to direct the management of the patients Crohns disease. The use of Anser testing has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. The effectiveness of Anser testing compared with conventional courses of action remains unproven. Patients being treated with adalimumab may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear. The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature (Karmiris, et al; Imaeda, et al; Lichtenstein, et al). These small studies demonstrate correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. The study by Karmiris and colleagues found no direct relationship between trough serum adalimumab concentration or anti-adalimumab antibody and short-term treatment efficacy. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. A review article concluded that Prospective controlled trials are directly needed to investigate the optimal tailored management in individual patients who lose response (Yanai and Hanauer). Therefore, clinical literature does not support Anser testing as definitively 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


A 66-year-old male enrollee has requested reimbursement for the unlisted chemistry procedure (84999) Prometheus Anser testing performed on 12/22/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease.  The physician reviewer found the use biologics such as Humira in treating Crohns disease has the potential for serious side effects including major opportunistic infections. This becomes important when a patient loses response to Humira, which entails increasing the dose. The concern between total loss of response or a completely different diagnosis entails different measures varying from surgery, change or increase in dose of biologic to symptomatic adjunct treatment. Hence, a blind management including increase of the dose may beget complications as under dosing compromises disease stability. Therapeutic levels and lack of antibodies may direct the treating provider toward a different drug versus another etiology. In this case, there is concern as the disease is quite advanced and the patient had already failed several regimen and flared on all. Therefore, the unlisted chemistry procedure (84999) Prometheus Anser testing performed on 12/22/15 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 1


A 43-year-old female enrollee has requested authorization and coverage for right sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain.   The physician reviewer found this patient presents with a history of right SI joint pain which is reported as severely debilitating. She has been diagnosed with sacroiliitis. There is no history of trauma. Clinical exam findings are generally consistent with SI joint pathology with positive FABER test, but do not document three positive exam findings consistent with evidence based medical guidelines. Right SI joint injections have provided greater than 50% improvement in pain. However, there are no imaging findings documented relative to the right SI joint that confirm sacroiliitis due to spondyloarthropathy. In addition, detailed evidence of a failure of conservative treatment has not been submitted. Moreover, there is an absence of evidence based medical peer-reviewed support for SI joint fusion for low back pain and lack of clear diagnostic findings isolated to the SI joint. For these reasons, the requested SI joint fusion 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


A 43-year-old female enrollee has requested authorization and coverage for right sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain.   The physician reviewer found that SI joint fusion has not been demonstrated in the peer-reviewed medical literature to provide superior health outcomes for treatment of low back pain. Overall, long-term outcomes and complications remain unknown. There is a lack of evidence of SI joint instability, fracture, or tumor. This patients records do not support a clinical justification for SI joint fusion. Thus, the requested right SI joint fusion 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.