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

Summary Reviewer 3


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 based on the current peer-reviewed medical literature, the requested sacroiliac fusion is not likely to be beneficial for management of chronic pain. Anatomical studies performed after the patient had an L3-4 level fusion and laminectomy suggests likely continuing pain generation from intervertebral disc and facet joints at multiple levels of the lumbosacral spine. The MRI did not show any abnormality in the sacroiliac joint and did not suggest that the sacroiliac joint had been violated by the bone graft. The reliance of steroid local injection into the sacroiliac joint as an indicator for identification of a specific pain generator, i.e. the sacroiliac joint is not sufficient to localize pain generation from the sacroiliac joint in the face of multifactorial chronic pain. In summary, it is not likely to be beneficial for this patient to undergo sacroiliac instrumentation and fusion as a treatment method for her condition of chronic pain. 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 47-year-old female enrollee has requested authorization and coverage for L5-S1 decompression with lumbar fusion, possible transforaminal lumbar interbody fusion (TLIF) and associated three inpatient days. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees back pain. The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  A review of the literature indicates moderate evidence of good outcomes from standalone lumbar fusions for chronic pain with or without instability. In this case, there is evidence of severe chronic low back pain associated with disc space collapse at L5-S1 and degenerative retrolisthesis. There is also evidence of facet arthritis and moderate bilateral neural foraminal narrowing and some displacement of the left S1 nerve root. As such, decompression combined with a fusion procedure is medically necessary. The medical evidence supports the requested services in this clinical setting. Therefore, L5-S1 decompression with lumbar fusion, possible transforaminal lumbar interbody fusion (TLIF) and associated three inpatient days are medically necessary for the treatment of this patient. Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 55-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 5/29/19. 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 has also been thought to add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individualas melanoma cells. It then classifies that particular melanoma based on the five-year risk of recurrence. Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma class, in patients undergoing sentinel node sampling. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear if the DecisionDx-Melanoma data can be used to make therapeutic decisions. National Comprehensive Cancer Network discusses the use of molecular assays in the treatment of cutaneous melanoma and does not currently recommend using the assay in other than clinical trial settings. Therefore, DecisionDx-Melanoma testing provided on 5/29/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 55-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 5/29/19. 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 this patient has an early stage melanoma. Commercially available gene expression profiling (GEP) tests are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear whether these tests provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariable nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. All told, DecisionDx-Melanoma testing provided on 5/29/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 55-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 5/29/19. 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. Thus, DecisionDx-Melanoma testing provided on 5/29/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 32-year-old male enrollee has requested reimbursement for gene testing performed on 3/12/19. 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 prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami reported on 217 patients, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients undergoing sentinel node biopsy. Berger reported on 156 cases, but there was not sufficient follow-up to determine the real value of the assay. It is not clear how the five-year DecisionDx-Melanoma data relates to the ten-year Balch data. Most importantly, it is unknown if the DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, gene testing performed on 3/12/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 32-year-old male enrollee has requested reimbursement for gene testing performed on 3/12/19. 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 patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines states while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. This patient had an early stage melanoma with good prognostic features on pathology. In sum, gene testing performed on 3/12/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 32-year-old male enrollee has requested reimbursement for gene testing performed on 3/12/19. 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 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 the DecisionDx-Melanoma assay 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. Thus, gene testing performed on 3/12/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 28-year-old male enrollee has requested reimbursement for Foundation One gene test performed on 4/7/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who was diagnosed with malignant peripheral nerve sheath tumor (MPNST). The physician reviewer found that the malignant peripheral nerve sheath tumors (MPNST) are an uncommon but devastating tumor of peripheral nerve. About 22 to 50 percent of MPNSTs occur in patients with neurofibromatosis type 1 (NF1). Having a NF1 mutation adds information for prognosis and aids in follow-up decision making. FoundationOne offers the advantage of testing for NF1 mutations as well as others that may help guide therapeutic decision making should the patient progress. FoundationOne testing is likely to be more beneficial than not testing and not knowing the prognosis of the patient. In sum, FoundationOne testing performed on 4/7/15 was likely to have been more effective over other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to have been 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 28-year-old male enrollee has requested reimbursement for Foundation One gene test performed on 4/7/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who was diagnosed with malignant peripheral nerve sheath tumor (MPNST). The physician reviewer found that the submitted records do not support the superior efficacy of the services at issue in this clinical setting. The record and clinical examination, history and features of this case do not suggest a diagnosis of NF1. The test requested by the treating provider was performed to test the primary tumor for NF1. Genetic testing for NF1 is a simple blood test. The FoundationOne test, which tests for a large number of genes is unproven and experimental. There is a lack of prospective randomized controlled studies showing improved outcomes correlating the results obtained from similar tests with improved overall survival, progression-free survival, or quality of life. These tests, while they may discover actionable genes, have yet to be correlated with improved outcomes. The services at issue are not recommended by governing scientific bodies such as the National Comprehensive Cancer Network. In sum, FoundationOne testing performed on 4/7/15 was not likely to have been superior over other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to have been 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 28-year-old male enrollee has requested reimbursement for Foundation One gene test performed on 4/7/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who was diagnosed with malignant peripheral nerve sheath tumor (MPNST). The physician reviewer found that MPNST are aggressive neoplasms of Schwann cells that are associated with neurofibromatosis (NF) type I but may also present sporadically. They may respond to the regimen noted here but eventually become chemotherapy resistant and fatal (Kroep, et al). In this patients case, he had exhausted the standard care options and is in need of therapy. There is molecular genetic evidence that supports a role for epidermal growth factor receptor (EGFR) signaling in MPNST. Direct blockade of EGFR signaling by tyrosine kinase inhibitors induces growth arrest and inhibition of metastases (Du, et al). This targeted therapy may offer some clinical benefit to this patient. Recently, a clinical study directly compared the use of targeted agents with conventional chemotherapy approaches. A study of 86 patients where the progression-free survival on regimen selected by molecular profiling was compared to progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage (Von Hoff, et al). This trial has very significant results for patients with stage IV tumors.  Invariably, this patient will be offered something off-label or a phase I/II clinical trial, but the results from molecular profiling offers a rational selection of the next regimen. Thus, the submission of his tissue for analysis to FoundationOne on 4/7/15, in an effort to guide next steps in his treatment, was likely to have been more beneficial than conventional therapies. Based upon the information set forth above, the services at issue were likely to have been 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 63-year-old male enrollee has requested reimbursement for anesthesia services performed on 12/18/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary during the enrollees colonoscopy procedure. The physician reviewer found the American Society of Anesthesiology (ASA) physical status classification system is utilized to assess the fitness of patients before surgery. According to the submitted record, the patient had an ASA preoperative physical status classification score of 2, which indicates no functional limitations. There is no documentation of clinical findings that would support the need for monitored anesthesia in this patients case. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist are well supported in both clinical practice and in the research. Therefore, given a low preoperative physical status classification score of 2, the anesthesia services performed on 12/18/15 were not medically necessary during the patients colonoscopy procedure. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 45-year-old female enrollee has requested authorization and coverage for Tazorac 0.1% cream.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found this patient has been diagnosed with keratosis pilaris, and she has been stably treated with Tazorac for greater than 10 years.  Keratosis pilaris is a common genetic condition resulting in build-up of the outer layer of skin at hair follicles, typically on the upper arms, thighs, buttocks and occasionally cheeks.  Treatment is most successful with keratolytic agents, including ammonium lactate, urea and salicylic acid preparations, or retinoid creams.  She has already tried and failed the typical preparations, but had success with Tazorac, a retinoid cream.  The request for coverage of this medication should be continued, as she has been treated successfully and stably for years with this medication and there is a lack of alternatives.  All told, Tazorac 0.1% cream is medically indicated for the treatment of this patient.  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 65-year-old male enrollee has requested reimbursement for genetic testing performed on 4/16/15.  The Health Insurer has denied this request indicating that the testing at issue was investigational for the evaluation of the enrollees medical condition.  The physician reviewer found that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard. The purpose of HLA-B5701 testing is to determine whether a person is likely to have an allergic reaction to abacavir. Abacavir (Ziagen) is found in several different combination regimens to treat HIV including Epzicom, Trizivir and the popular single tablet regimen Triumeq. HLA-B5701 testing is strongly recommended in most treatment guidelines prior to starting abacavir or an abacavir containing regimen. This patient is highly treatment experienced and is likely to harbor resistance to several classes of HIV medications. It is likely that he may require an abacavir-containing regimen. It will certainly be part of the consideration any time this patient will be changing medications for any reason including simplification, resistance, avoiding nephrotoxicity or bone mineral density decreases. Most HIV providers order HLA-B5701 testing, as part of the initial evaluation of an HIV patient and prefer to have the results on all patients with HIV prior to the time when abacavir is required. Waiting until abacavir is needed prior to sending the test causes delay in treatment in some cases and requires patients to return for additional office visits and blood draws.  The amount of delay may vary widely based on the availability of the testing and ability for patients to access the clinic. While some providers and patients are able to accommodate this, for others it constitutes an unacceptable delay in treatment and undue burden on the patient. These burdens can be severe if testing is not readily available or patients live far from their clinic, have transportation or other access issues. For this reason, several highly regarded HIV guidelines (Clumeck, et al) recommend that HLA-B5701 be tested on all patients initially rather than wait for abacavir use. It is a test needed only once in the lifetime of the patient. Therefore, the testing 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 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 Overturned

Summary Reviewer 2


A 65-year-old male enrollee has requested reimbursement for genetic testing performed on 4/16/15.  The Health Insurer has denied this request indicating that the testing at issue was investigational for the evaluation of the enrollees medical condition.  The physician reviewer found that HLA-B5701 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. HLA-B5701 testing is utilized to predict the occurrence of side effects to one anti-HIV drug (abacavir). In this case, abacavir was not part of the patients drug regimen at the time he was seen on 4/16/15. In addition, there is a lack of documentation suggesting a treatment plan to order abacavir. The record reflects that the patient was being treated with Tivicay and Complera with good results. As such, the testing at issue 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.