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

Summary Reviewer 1

A 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/17/19. 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. There are two important decision points in the treatment of cutaneous melanoma. The first is
whether or not to do sentinel node; the pathology alone here strongly indicates that the procedure should be done. The second issue is that of whether adjuvant therapy should be given. Coupling the initial pathology, along with the results of the sentinel node, would give enough information to make the decision about adjuvant therapy.
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 metastasis. Gerami reported on 217 cases and found good correlation between DecisionDx-Melanoma testing prediction and prognosis in patients undergoing sentinel node biopsy. However, it is not clear how the DecisionDx-Melanoma testing five-year data compares to the ten-year Balch data. Most importantly, it is not known if it can be used to make therapeutic decisions beyond those that can be made on the pathologic data. Therefore, DecisionDx-Melanoma testing performed on 5/17/19 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/17/19. 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. Therefore, DecisionDx-Melanoma testing performed on 5/17/19 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/17/19. 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 very novel and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Therefore, DecisionDx-Melanoma testing performed on 5/17/19 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 60-year-old female enrollee has requested reimbursement for laboratory services provided on 8/15/19. The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that FoundationOne assay explores possible mutations in 324 genes, as well as certain other abnormalities, in an individualas cancer cells. At this time, there is a lack of convincing evidence that therapy that is determined by the assay is superior to that which an oncologist would recommend from the literature and experience. Finding a mutation does not guarantee that a treatment directed at that will be effective. It has been estimated that the percentage of patients who would benefit from using the assay to select therapy is quite small. The National Comprehensive Cancer Network guidelines for treatment of ovarian cancer does not recommend using such an assay in the selection of therapy. Therefore, laboratory services provided on 8/15/19 were not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 60-year-old female enrollee has requested reimbursement for laboratory services provided on 8/15/19. The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that individualized molecular tumor profiling holds the promise of enabling personalized selection of molecularly targeted treatment based on the specific genotype identified. The National Comprehensive Cancer Network guidelines recommend tumor molecular testing prior to initiation of therapy for recurrent or persistent ovarian cancer, if not previously done. Testing should include at least BRCA1/2, homologous recombination pathway genes, and microsatellite instability or DNA mismatch repair. Knowing if a patient has a somatic mutation in a BRCA gene helps select maintenance therapy after primary treatment. Molecular profiling is now considered a standard of care in patients with ovarian cancer. Therefore, laboratory services provided on 8/15/19 were likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 60-year-old female enrollee has requested reimbursement for laboratory services provided on 8/15/19. The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that this patient has advanced ovarian cancer. She has been appropriately treated with debulking surgery and will likely receive multi-agent chemotherapy that includes cisplatin. Thereafter, she will need close follow-up to identify recurrence. According to the NCCN guidelines, it will be important to know the presence of germline or somatic mutations in BRCA1 and/or BRCA2. She may be offered maintenance therapy based upon mutation status. She may also be eligible for clinical trial based on her mutational status. Therefore, laboratory services provided on 8/15/19 were 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 15-year-old female enrollee has requested reimbursement for residential mental health treatment for children and adolescents provided from 11/27/17 through 1/20/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining necessary level of care for children. With regards to risk of harm, the records support a score of 3 due to her inability to control impulsive aggression towards staff. In terms of her functional status, the records support a score of 4 due to deterioration in interpersonal interactions and serious school disruption. With regards to her comorbidity, the records support a score of 1. The patient did not have active medical problems and did not have a recent history of substance use. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had school disruption and lack of peer support. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment on a regular basis. In terms of resiliency and treatment history, the records support a score of 5 due to minimal positive treatment response in the past at numerous levels of care. In terms of acceptance and engagement of the patient, the records support a score of 5. The patient had minimal insight into her treatment needs. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians. Thus, the patient has a composite score of 24, which is consistent with residential level of care. The medical evidence supports the services at issue in this clinical setting. Therefore, residential mental health treatment for children and adolescents provided from 11/27/17 through 1/20/18 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 56-year-old female enrollee has requested reimbursement for Oncotype DX colon cancer assay completed on 8/19/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found that there is support in the medical literature for the services at issue in this clinical setting. Oncotype DX assay is a 12 gene panel that predicts the risk of recurrence in both stage II and III colon cancer (Yothers, et al; Yamanaka, et al). Moreover, a review by You and colleagues supported the use of Oncotype assay in the decision about adjuvant chemotherapy. Most oncologists make this decision based on specific pathologic and clinical features in an individual's situation. Among those features that predict for a higher risk of recurrence are poorly differentiated histology, lymphovascular invasion, presentation with obstruction or perforation, or a T4 tumor. Of these features, only the fact that there was perforation at the time of diagnosis is applicable in this patients case. This factor alone does suggest the possible need for adjuvant chemotherapy. This test is useful in a situation wherein there is an adverse feature (perforation), upon which to base the decision for chemotherapy. All told, the use of Oncotype DX colon cancer assay completed on 8/19/15 was likely to be more effective than the standard options for the evaluation of this patient. Therefore, for the reasons stated 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 56-year-old female enrollee has requested reimbursement for Oncotype DX colon cancer assay completed on 8/19/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found that this patient had stage II colon cancer. Although Oncotype DX colon cancer assay provides prognostic data, to date, it does not provide predictive data for the benefit of chemotherapy.  Per the medical evidence, the clinical utility of gene expression assays, including the 12-gene recurrence score, is uncertain. Information is lacking regarding the extent to which assay results do or do not classify patients into distinct groups with clinical relevance.  National Comprehensive Cancer Network guidelines state that there are insufficient data to recommend the use of multigene assays, such as the Oncotype DX colon cancer, to determine adjuvant therapy.  The perforation of this patients tumor despite negative nodes would favor treatment with chemotherapy. As such, the use of Oncotype DX colon cancer assay on 8/19/15 was not likely to have been more beneficial than using standard factors in determining the need for adjuvant therapy for the evaluation of this patient.  Therefore, for the reasons stated 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 56-year-old female enrollee has requested reimbursement for Oncotype DX colon cancer assay completed on 8/19/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found that there is some evidence to consider adjuvant treatment for those stage II patients with T4 disease, obstructing lesions, and other biomarkers.  The Oncotype DX colon cancer assay uses a reverse transcriptase-polymerase chain reaction assay for 12 genes in an algorithm that can be used to predict recurrence. The medical evidence for the test is sufficient to allow its use to estimate the risk of recurrence for stage II patients when incorporated with other tests, such as standard pathology and microsatellite instability testing. This patient has been diagnosed with stage II cancer. Thus, Oncotype DX colon cancer assay performed on 8/19/15 was likely to have been more effective than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 25-year-old male enrollee has requested authorization and coverage for upper jaw surgery. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who has been diagnosed with obstructive sleep apnea syndrome. The physician reviewer found that there is sufficient support in the medical literature for the requested services in this clinical setting.  Studies have shown that the presence of abnormalities in the anterior maxilla results in a high nasal floor, which constricts the nasal passageways and causes increased nasal airway resistance. Surgical correction results in improved nasal breathing which is a result of a widened airway space brought about by maxillary arch expansion. This may be accomplished by a number of techniques which may include rapid palatal expansion, surgical assisted rapid palatal expansion, and segmental Le Fort I osteotomies. The submitted documentation notes an intolerance to CPAP and an RDI score of 23.8. Given this patients symptoms, surgical correction is indicated. In sum, the requested upper jaw surgery is medically necessary for the treatment of this patients medical condition.Therefore, for the reasons stated above, 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 54-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy less than 12 months due to non-liver-related conditions.  The guidelines support Harvoni for treatment-naive patients with hepatitis C, genotype 1 infection.  It is advantageous to treat patients before they progress to cirrhosis.  Based on evidence of safety and efficacy in the published literature, the requested medication Harvoni 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 43-year-old female enrollee has requested authorization and coverage for Contrave. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees morbid obesity. The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. According to the documentation provided, this patient falls into a class III (high risk) obesity. She has not had success with diet or exercise, or with the weight loss medication Belviq.  She also has multiple comorbidities such as hypertension, borderline diabetes, and obstructive sleep apnea (Jensen, et al). Contrave is U.S. Food and Drug Administration approved for chronic weight management in patients with BMI over 30 (package insert).  Guidelines for pharmacological management of obesity released in 2015 by the Endocrine Society state that patients who have a history of being unable to successfully lose and maintain weight are candidates for weight loss medications (Apovian, et al). Specifically, pharmacotherapy is recommended in patients with BMI higher than 30 kg/m2 (or 27 if comorbidities are present). This patient had a BMI of 45.2 kg/m2 in May 2017. Studies have shown 8.2% weight loss at one year, with approximately 40% of patients losing more than 10% of their weight (Sherman, et al).  For these reasons, the request for Contrave is supported as medically necessary for the treatment of the patients medical condition.Therefore, for the reasons stated above, the requested medication is 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 52-year-old female enrollee has requested reimbursement for computed tomography (CT) scan of the sinuses performed on 1/12/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical literature supports the use of CT scan in diagnosis and treatment planning in the setting of chronic recurrent rhinosinusitis.  However, it is not within standard of care to repeat a scan in this clinical setting.  There is no medical indication for this patient to have undergone a second CT one month after a prior scan showed lack of disease.  All told, the CT scan of the sinuses performed on 1/12/16 was not medically indicated in this particular situation.  Therefore, the services at issue were 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 

A 52-year-old male enrollee has requested reimbursement for knee orthosis provided on 12/15/17. The Health Insurer has denied this request indicating that the equipment at issue was not medically necessary for treatment of the enrollee, who was diagnosed with complex tear of the medial meniscus. The physician reviewer found that the submitted documentation does not demonstrate the medical necessity of the equipment at issue. In this patients case, the records document a medial meniscal tear and contusion of the medial compartment. The provider recommended arthroscopic partial medial meniscectomy and a valgus off-loader knee orthosis. The literature does not support the use of off-loader braces after medial meniscectomy. The current medical evidence does not support the equipment at issue in this clinical setting. Dammerer and colleagues concluded that 12 weeks of compartment-unloading therapy, with either a knee brace or wedge insoles, is ineffective with regard to clinical outcome after arthroscopic partial meniscectomy. Thus, knee orthosis provided on 12/15/17 was not medically necessary for the treatment of this patient. Therefore, the equipment 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 53-year-old female enrollee has requested reimbursement for gene testing performed on 11/15/16. 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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may also add a bit more to these prognostic statistics. As per these criteria, this patients melanoma would be classified as a stage 1A, with an expected ten-year survival of at least 88%. DecisionDx is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either Class 1 (with a 90-96% five year distant metastasis-free survival) or Class 2 (with a 65-80% rate). Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx classification, in patients undergoing sentinel node sampling, which was not documented in this case. Berger and colleagues reported on 156 cases, but there was not sufficient follow-up to determine the actual value of the assay. It is not clear how the five-year DecisionDx data compares to the ten-year Balch data, and whether it can be used to make clinical decisions. This would be particularly at issue in this patient given her excellent prognosis. All told, gene testing performed on 11/15/16 was not likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were 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.