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

Summary Reviewer 2


A 41-year-old male enrollee has requested reimbursement for Decision DX Melanoma Assay performed on 12/16/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  The prognosis of cutaneous melanoma has classically been determined by the staging system spelled out by Balch.  Mitotic index has also been thought to add a bit more to the prognostics.  Although the pathology report in this case listed his stage as pT1b, it appears that in the absence of ulceration, and a penetration only to Clark Level III, he is really stage pT1a.  By these determinations, he has at least a 95% five-year and 88% ten-year survival.  Decision DX Melanoma Assay is a study of 31 genes in the melanoma cells.  It then classifies that particular melanoma as either class 1 (with a 97% disease free rate at five years) or class 2 (with a 31% disease free rate at five years). Gerami reported that there was good correlation between prognosis and Decision DX classification.  However, it is not clear how Decision DX Melanoma Assay data compares to the ten-year data of Balch determinations, and whether it can be used prospectively in clinical practice. This is especially in question in this particular patient with his pathologic findings and excellent prognosis.  In sum, Decision DX Melanoma Assay performed on 12/16/15 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 41-year-old male enrollee has requested reimbursement for Decision DX Melanoma Assay performed on 12/16/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. 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 they suggest a high-risk for the development of metastatic disease in the future.  Such patients may be observed or treated with interferon-alpha.  There is little data on the services at issue in this clinical setting.  The test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques.  Thus, Decision DX Melanoma Assay performed on 12/16/15 was not likely to be more effective 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 56-year-old male enrollee has requested reimbursement for a polysomnography performed on 4/27/15. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was not medically necessary for evaluation of the enrollees snoring. The physician reviewer found that in this case, the patient presented with multiple symptoms strongly suggestive of obstructive sleep apnea, both on the basis of his reported symptoms and his medical history. While polysomnography has traditionally been used to evaluate patients with obstructive sleep apnea, there has been a paradigm shift towards testing for obstructive sleep apnea in the home environment. As a result, it has become more common to test patients with suspected obstructive sleep apnea with unattended sleep testing. Such testing has been shown to be equally beneficial in terms of the establishment of obstructive sleep apnea as lab testing in a less intense environment. In this case, there is a lack of documentation of any contraindications to unattended testing. Given that there has been a change in this diagnostic paradigm towards ambulatory testing, the services that were performed exceeded the patients clinical needs. Thus, the polysomnography performed on 4/27/15 was not medically necessary for evaluation of this patients medical condition. 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 Overturned

Summary Reviewer 

The patient is a 96-year-old male with a history of ongoing eczema.  The patient has requested authorization and coverage for Dupixent 300 mg. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that Dupixent is used for chronic eczema that is moderate to severe. This patient has moderate-to-severe disease that is interfering with his daily activities, like sleep. He has tried many traditional treatments without success. Dupilumab (Dupixent) is safe, effective, and U.S. Food and Drug Administration (FDA) approved for the treatment of moderate-to-severe atopic eczema. It would be medically reasonable and necessary for this patient to use Dupixent to treat his refractory moderate-to-severe eczema. There are multiple trials showing its efficacy and safety. Therefore, Dupixent 300 mg is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 54-year-old female enrollee has requested reimbursement for color-flow Doppler echocardiography performed on 3/29/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees chest pain and dyspnea. The physician reviewer found that this patient had risk factors for coronary heart disease and symptoms of both chest pain and dyspnea. She was referred for color-flow Doppler echocardiography. Given her symptoms of chest pain and dyspnea, along with the fact that this was the first and only investigation of these complaints, assessment of her cardiac valves and pulmonary pressures was reasonable, indicated and appropriate in order to rule out both ischemic and valvular heart disease as an etiology of her chest pain and dyspnea symptoms. Therefore, color-flow Doppler echocardiography performed on 3/29/18 was likely to have been more efficacious 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 54-year-old female enrollee has requested reimbursement for color-flow Doppler echocardiography performed on 3/29/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees chest pain and dyspnea. The physician reviewer found that the records document increased coronary risk and symptoms suspicious for coronary ischemia. Overall, the patients pre-test risk based on her risk factors, age and symptoms was at least moderate. In this circumstance, a test with increased sensitivity such as a stress echocardiogram is preferable and appropriate compared to a regular treadmill electrocardiogram with a reduced sensitivity of about only 60 to 70%.  In addition, the stress echocardiogram is able to assess for other potential causes of the patients exertional dyspnea, such as cardiomyopathy or occult valvular disease. Current guidelines endorsed by several national organizations also consider stress echocardiogram appropriate in this circumstance. The medical evidence supports the use of color-flow Doppler echocardiography in this patients case. In sum, color-flow Doppler echocardiography performed on 3/29/18 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 Overturned

Summary Reviewer 3

A 54-year-old female enrollee has requested reimbursement for color-flow Doppler echocardiography performed on 3/29/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees chest pain and dyspnea. The physician reviewer found that there is sufficient support for the services at issue in this patients case. Although in general the evaluation of chest pain in the absence of physical evidence of valvular heart disease or intracardiac shunting can be accomplished without the additional performance of a color-flow Doppler examination with stress echocardiography, there is additional relevant clinical information which may be gleaned from a color-flow Doppler evaluation in the evaluation of unexplained dyspnea, which is the other cardiac symptom that this patient had.  This information includes the presence of pulmonary hypertension as well as intra-atrial shunting among other diagnoses which may be silent on physical examination. The services at issue were appropriate in order to fully evaluate the patients symptoms. Thus, color-flow Doppler echocardiography performed on 3/29/18 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a nine-year-old female enrollee has requested reimbursement and prospective authorization and coverage for 33 hours per week of applied behavioral analysis (ABA) therapy provided from 5/18/15 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 autism spectrum disorder (ASD). The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. ABA has been shown in the medical literature to be effective for children and preschoolers with autism spectrum disorders. Reichow and colleagues performed a review showing that early intensive behavioral intervention is effective to increase IQ, improve communication and adaptive skills. In addition, Mohammadzaheri and colleagues examined the use of ABA and pivotal response treatment in school age children with autism and disruptive behavior. The authors found these interventions to be very effective in decreasing maladaptive and disruptive behaviors even in school age children. Based on the documentation submitted for review, the patient presents with behaviors of pica and mouthing non-food items, which can be dangerous. The mouthing of non-food items can lead to infections and also to bezoar, impactions, and other events requiring surgical intervention. Furthermore, this patient has made slow progress with her current level of services in adaptive, communication and behavioral domains. Based on the documentation submitted for review a decrease in ABA hours is not indicated. Self-injury is primarily improved with communication skills. The research study by Richards and colleagues showed that the children with the worse self-injury had higher levels of autism symptoms and lower levels of communication skills. The most effective intervention for pica and to prevent surgical interventions is behavioral interventions. Based on the support in the peer-reviewed literature and the severity of the patients behaviors, the request for 33 hours per week of ABA was and is medically necessary for treatment of the patients medical condition.Therefore, the services at issue were and 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 44-year-old male enrollee has requested reimbursement for the allergy immunotherapy treatment provided on 11/2/15. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees Menieres disease and allergic rhinitis. The physician reviewer found that in the medical literature, Cox and colleagues noted that the intervals between maintenance immunotherapy injections generally range for four to eight weeks for venom and every two to four weeks for inhalants allergens but can be advanced as tolerated if clinical efficacy is maintained. In this case, the patient should be well into the maintenance phase, which does not require weekly injections. At times, providers will decrease doses if doses are missed, there are adverse reactions, or during pollen season. Larenas-Linnemann and colleagues report that doses are reduced when a patient comes in more than 14 days for five weeks after the last administration and initial dosing restarted after more than 30 days for 12 weeks since last administration during the build-up or maintenance stage. After missing one to three doses, the dosing schedules were mostly followed (build-up phase: repeat last dose, reduce by one dose, reduce by two doses; maintenance phase: reduce by one dose, reduce by two doses, reduce by three doses). For this patient, there is no evidence of missed doses, adverse events or other issues with allergy injections. As such, allergy immunotherapy treatment provided on 11/2/15 was not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the medication at issue was 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 57-year-old male enrollee has requested reimbursement for residential treatment services provided from 11/12/14 through 12/3/14. 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 based on the above information, the patient did not meet medical necessity criteria for residential treatment services from 11/12/14 through 12/3/14. There is no evidence that less intensive treatment was not sufficient or appropriate to effectively treat the patient, since he had participated in an adequate trial.  The patients level of symptomatology did not justify continued residential treatment during the period at issue. No suicidal ideations or homicidal ideations were documented. The patient did not show evidence of serious psychomotor excitation or aggression. Severe affective dysregulation was not reported. The patient did not appear to have any serious psychosocial functional or interpersonal skills deficits. Furthermore, the patient has not attempted less restrictive, less intrusive services prior to the admission at issue. At the time of admission it was noted that the patients affect was labile but there was no evidence of psychosis, and no evidence of suicidal or homicidal ideation. Multiple progress notes including on 11/5/14 and 11/10/14 noted good mood, no suicidal ideations and no evidence that suggested a need for 24-hour care. All told, there was no reasonable expectation that residential care would have significantly improved the patients symptoms over a less restrictive level of care such as outpatient individual counseling and outpatient medications management. 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 36-year-old male enrollee has requested authorization and coverage for implantation of hypoglossal nerve stimulator. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees sleep apnea. The physician reviewer found that While there is some support in the medical literature for the requested procedure, there is a lack of independent data establishing the superior efficacy of this treatment in this clinical setting. A review of the literature indicates that hypoglossal nerve stimulation for treatment of OSA may show beneficial outcomes with minimal adverse effect. However, there are a lack of studies that directly compare outcomes of hypoglossal nerve stimulation to current standard therapies. As such, the implantation with hypoglossal nerve stimulator is not likely to be more beneficial than standard available therapy for treatment of this patient. Therefore, for the reasons stated 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 Overturned

Summary Reviewer 2

A 36-year-old male enrollee has requested authorization and coverage for implantation of hypoglossal nerve stimulator. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees sleep apnea. The physician reviewer found that the available clinical studies and recent medical evidence demonstrate that implantation of hypoglossal nerve stimulator can be an effective technique in improving this patients symptoms. The American Academy of Otolaryngology Head and Neck Surgery considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with CPAP. Woodson and colleagues indicate that patients achieve a definite benefit from the implantation and electrical stimulation of the hypoglossal nerve for treatment of OSA. Clinical studies also recommend that patients benefit from this device when they have a BMI less than 32. This patients BMI was noted to be 31.9. This patient meets clinical criteria for surgical management of the OSA symptoms and has undergone extensive evaluation of the problems associated with sleep deprivation. This patient has trialed CPAP therapy for airway management with failure to control symptoms of OSA, and was intolerant of CPAP. While alternative surgical methods are available, this patient has narrowing of the hypopharyngeal and anterior/posterior palatal airway on sleep endoscopy and meets criteria for the implantation technique. In summary, implantation of hypoglossal nerve stimulator is likely to be more effective for treatment of the patients medical condition than the available alternatives. Therefore, for the reasons stated above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 36-year-old male enrollee has requested authorization and coverage for implantation of hypoglossal nerve stimulator. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees sleep apnea. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. OSA is an increasingly prevalent clinical problem. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. The Stimulation Therapy for Apnea Reduction (STAR) trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA (Woodson, et al). This trial demonstrated that hypoglossal nerve stimulator is safe and effective in a small subset of patients with OSA who have failed CPAP. With a BMI of 31.9, AHI of 43.9 and nonconcentric airway collapse, this patient meets the criteria. He has failed CPAP which is the gold standard treatment for OSA and has also failed upper airway sleep surgery. He remains at risk for untoward cardiac sequelae of untreated OSA. All told, implantation with a hypoglossal nerve stimulator is likely to be of greater benefit than the standard modalities for treatment of this patients medical condition. Therefore, for the reasons stated above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 22-year-old male enrollee has requested reimbursement for residential mental health treatment for adults provided from 1/14/19 through 2/08/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation with any active intent or plan and no history of suicidality. With regards to functional status, the records support a score of 2 due to overall good functional level in treatment but consideration of functional problems, including withdrawing from school when in the community and using substances. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and history of psychotic symptoms that appear under adequate control. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable living environment. In terms of level of support of the recovery environment, the records support a score of 2 due to an overall supportive recovery environment. In terms of treatment and recovery history, the records support a score of 3 due to some motivation for treatment but no past significant substance use treatment mentioned in the records. With regards to engagement and recovery status, the records support a score of 2 due to cooperation in treatment. Thus, the patient has a composite score of 14. This score correlates with low-intensity community-based services. Therefore, residential mental health treatment for adults provided from 1/14/19 through 2/08/19 was not medically necessary for the treatment of this patient.