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

Summary Reviewer 3


A 32-year-old female enrollee has requested reimbursement for prenatal testing performed on 1/10/14. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees suspected fetal abnormality. The physician reviewer found non-invasive prenatal testing uses cell-free fetal DNA from the plasma of pregnant women to detect trisomy 13, 18 or 21 (Sparks, et al.). The American College of Obstetrics and Gynecology has recommended that women, regardless of maternal age, be offered prenatal assessment for aneuploidy either by screening or invasive prenatal testing. Cell-free DNA is now another option that can be used as a primary screening test in women at an increased risk of aneuploidy. Increased risk women include maternal age 35 years or older with fetal findings indicating an increased risk of aneuploidy. In this case, the patient was at an increased risk of aneuploidy, given the fetal ultrasound findings indicating an increased risk of trisomy. The patients anatomic screen demonstrated two soft signs, and for this reason the cell-free DNA screening was clinically indicated and likely to be more beneficial for evaluation of the patients medical condition. 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 24-year-old male enrollee has requested reimbursement for Rituxan provided on 12/17/18. The Health Insurer has denied this request and reported that the medication at issue was not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that pediatric autoimmune neuropsychiatric disorder is a term used to describe a patient with OCD or tic disorders which are made worse by group A streptococci. The association between pediatric autoimmune neuropsychiatric disorder and group A streptococci is controversial. Furthermore, the idea that pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS) is an autoimmune disorder is controversial. Immune modulating treatment is not routinely recommended. The treatment of choice for OCD includes cognitive-behavioral therapy, a selective serotonin reuptake inhibitor medication, or both. In this case, the patient has diagnoses of schizophrenia, OCD and PANDAS. Rituximab is an antineoplastic agent, monoclonal antibody immunosuppressant agent. It is not approved by the U.S. Food and Drug Administration for the treatment of OCD, schizophrenia or PANDAS. Therefore, Rituxan provided on 12/17/18 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 26-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/15/19. 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 the staging system spelled out by Balch. Mitotic index is thought to add a bit to these statistics. DecisionDx-Melanoma testing is an assay of the molecular and genetic changes in an individualas melanoma cells. It then classifies that 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 DecisionDx-Melanoma data can be used to make clinical decisions, such as whether to do a sentinel node or not. Therefore, DecisionDx-Melanoma testing performed on 4/15/19 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 26-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/15/19. 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 various (mostly retrospective) studies of prognostic gene expression profiling (GEP) testing suggest its role as an independent predictor of worse outcome, although not superior to Breslow thickness or sentinel lymph node status. It remains unclear whether this GEP profile is reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation studies are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Existing and emerging GEP platforms and other prognostic techniques should also be compared with optimized contemporary multivariable phenotypic models. Therefore, DecisionDx-Melanoma testing performed on 4/15/19 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 26-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/15/19. 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. Therefore, DecisionDx-Melanoma testing performed on 4/15/19 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 seven-year-old male enrollee has requested reimbursement for a tonsillectomy and adenoidectomy performed on 10/27/15. The Health Insurer has denied this request indicating that the surgery at issue was not medically necessary for treatment of the enrollees recurrent strep throat. The physician reviewer found that this case involves justification of the surgical intervention performed on the patient because of recurring episodes of acute pharyngitis and tonsillitis with positive cultures and requirements for antibiotic therapy. Tonsillectomy and adenoidectomy is a well-recognized surgical procedure for the treatment of patients with episodes of recurring acute pharyngitis and tonsillitis poorly controlled with outpatient antibiotic therapies. Multiple case studies have demonstrated that surgical removal of the infected source of the Streptococcal infections by removal of the tonsils and adenoids leads to improvement and reduction of the episodes of these acute infections (Baugh, et al). Clinical studies also indicate that patients who have multiple bouts of Streptococcus positive cultures, such as the patient in this clinical scenario, benefit from surgery to reduce the recurrence of these episodes (Burton, et al). This patient had clear documentation of recurrent episodes of culture positive pharyngitis and tonsillitis. Therefore, the tonsillectomy and adenoidectomy performed on 10/27/15 was medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the surgery at issue was 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 51-year-old female enrollee has requested authorization and coverage for Sovaldi and ribavirin. The Health Insurer has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 2b.  The physician reviewer found that due to the approval and availability of new therapies, clinical guidelines and accepted standards of care were completely revised in late 2014. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C genotype 2, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Additionally, treatment of patients before they progress to F3 or F4 fibrosis is advantageous. Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested Sovaldi and ribavirin are medically necessary for treatment of this patients medical condition. Consistent with these findings, the requested medications are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 43-year-old female enrollee has requested reimbursement for residential treatment center services provided from 5/27/17 through 6/26/17. The Health Plan 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 based on the Level of Care Utilization System (LOCUS) criteria, as of 5/27/17, the patient met criteria for treatment in a less restrictive environment. The patients risk of harm score is two (2), low risk of harm. The patient does not have any prior history of suicide attempts. On admission, the patient did not have any suicidal ideation. The patient was able to care for herself. The patient did not have any legal problems. The patients functional status score is three (3), moderate impairment. The patients substance use led her to lose her job. She was unable to fulfill responsibilities and obligations in her job. The patients medical, addictive and psychiatric co-morbidity score is three (3), significant co-morbidity. The patient has a significant co-morbidity of alcohol use disorder, depression, migraine headaches, and hypertension. The patients recovery environment score is two (2), mildly stressful environment. The patient is single and has two children, ages 10 and 13. Potential for alcohol exposure exists at her home. The patients level of support score is two (2), supportive environment. The patients parents are supportive of the patient. The patient also has community support in Alcoholics Anonymous. The patients treatment history score is three (3), moderate response to treatment and recovery. The patients prior treatments have been modestly successful. She had obtained five months of sobriety prior to the residential treatment center admission. The patient also had 70 days of sobriety while receiving treatment as an outpatient. The patients engagement and recovery status score is two (2), positive engagement and recovery. The patient was motivated for recovery and cooperative with staff. She would accept and participate in treatment. Based on these criteria, the patient had a total score of 17 and met criteria for an intensive outpatient program (IOP). Therefore, the residential treatment center services provided from 5/27/17 through 6/26/17 were not medically necessary for treatment of the patients medical condition. 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 50-year-old male enrollee has requested authorization and coverage for Repatha SureClick. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hypercholesterolemia.  The physician reviewer found that Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient does not fit either of those criteria. The presence of coronary calcium does not equate to coronary obstruction, and there is no documented obstructive coronary stenosis or clinical cardiovascular disease, such as stroke, myocardial infarction, angina, ischemia on stress testing, or prior coronary revascularization. PCSK9 inhibitors have not been adequately studied in other patient populations, such as this patient with an elevated calcium score but no documented clinical cardiovascular disease. The current guidelines do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Thus, Repatha SureClick is not medically necessary for the treatment of this patient. Therefore, 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 parent of a 16-year-old male enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services provided from 1/31/17 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found that the records provided for review do not support the medical necessity criteria for RTC services from 1/31/17 forward for treatment of this patients behavioral health issues. The patient did not demonstrate behaviors suggesting that he was at imminent risk of harm to self or others. The patients psychiatric issues prompting admission could have been safely and efficiently been treated at a less intensive setting. The patient has also not shown to have any acute impairment in behavior or issues with cognition that interfered with activities of daily living. Psychosocial and environmental problems were not likely to threaten the patients safety and did not undermine engagement at a less intensive level of care, such as outpatient care. All told, the patient did not require 24-hour supervision and management at the RTC level of care from 1/31/17 forward. Based on the foregoing discussion, the services at issue were not and 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 Upheld

Summary Reviewer 

The parent of a five-year-old male enrollee has requested reimbursement for albendazole provided on 3/01/18. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees medical condition.The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication at issue. This patient does not have documented parasitic infection. There is some use of albendazole in children on the autistic spectrum that have gastrointestinal issues, but in the absence of positive cultures, this would be considered off-label usage and not consistent with the current standard of care. The medical evidence does not support the medication at issue in this clinical setting. Therefore, albendazole was not medically necessary in this patients case. Therefore, the medication at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 49-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma assay provided on 2/14/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. While the majority of clinical stage I patients will be disease-free at five years, some stage I patients will develop advanced disease. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. DecisionDx-Melanoma assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class 1 consistent with a low risk of metastasis or Class 2 suggestive of a high risk of metastasis. One peer-reviewed publication indicated that there was a statistically significant association of a Class 1 signature by DecisionDx-Melanoma assay for primary dermal melanoma (PDM), whereas cutaneous metastatic melanoma (CMM) were more frequently Class 2 (Sidiropoulos, et al). The authors concluded that the melanoma prognostic assay may be a useful tool for distinguishing PDM from CMM. According to the results of analysis of this patients melanoma performed with DecisionDx-Melanoma assay, the tumor was classified as Class 1 with a low risk of near-term (within five years) metastatic disease. Therefore, DecisionDx-Melanoma signature may be an independent predictor of metastasis risk. However, there is a lack of peer-reviewed published studies confirming this hypothesis. Accordingly, the DecisionDx-Melanoma assay performed on 2/14/17 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 49-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma assay provided on 2/14/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of this patients melanoma. Moreover, the DecisionDx-Melanoma gene assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma assay provided on 2/14/17 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 3

A 49-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma assay provided on 2/14/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the DecisionDx-Melanoma assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx test has shown some impressive accuracy in thin melanomas like this patients tumor. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. The test has not been demonstrated to provide a beneficial effect on health outcomes. Overall, there is not enough published data to support its routine use. Since this test has not been demonstrated to provide a greater benefit beyond that anticipated with established tests, the DecisionDx-Melanoma assay provided on 2/14/17 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 33-year-old female enrollee has requested reimbursement for DecisionDX melanoma gene expression profiling assay.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees malignant melanoma.   The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  In this clinical setting, at least a 95% five-year survival and an 88% ten-year survival is predicted based on staging described by Balch and mitotic index.  DecisionDX is a study of 31 genes in the melanoma cells.  It then classifies that particular melanoma as either Class 1 (97% disease-free rate at five years) versus Class 2 (31% disease-free rate at five years).  Per the medical evidence, there is good correlation between prognosis and DecisionDX classification.  However, it is not clear how DecisionDX data compares to the ten-year data of the Balch determinations, and whether it can be used in clinical practice.  This is significant in this patients case given her pathologic findings and excellent prognosis.  This assay was not expected to be of clinical benefit in this case.  All told, DecisionDX melanoma gene expression profiling assay was not medically indicated for the treatment of this patient.  Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.