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

Summary Reviewer 3

A 26-year-old female enrollee has requested authorization and coverage for Xeljanz 5 mg The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees alopecia areata. The physician reviewer found that there is sufficient support for the requested medication in this patients case. Per the records, Xeljanz resulted in excellent regrowth of her hair. The use of Xeljanz for extensive alopecia areata and alopecia totalis has been very promising. There are currently case series in the literature and clinical trials evaluating the efficacy of this treatment on alopecia areata. There is a lack of U.S. Food and Drug Administration (FDA) approved medications for the treatment of this condition, and the use of tofacitinib has been shown to be effective in this setting. There are no other more effective therapies that can be offered as an alternative. Thus, Xeljanz 5 mg is likely to be superior over other available treatment options. Based upon the information set forth above, the requested medication is 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 1

A 53-year-old female enrollee has requested authorization and coverage for autologous cultured chondrocytes implant knee. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that autologous chondrocyte implantation is a proven method for salvage of large articular cartilage defects of the patellofemoral joint in the long-term. Focal chondral defects of the knee can significantly impair knee function, cause chronic pain, and affect the quality of life. The autologous chondrocyte implantation technique has evolved over the past 20 years.  The newest technique is the third-generation technique called matrix-induced autologous chondrocyte implantation, which has been recommended in this patients case. Physical examination, imaging studies, and arthroscopic findings have been utilized in this case to identify the articular defects. Conservative measures have been exhausted, and surgical treatment is indicated for the patellofemoral joint. Patients treated with matrix-induced autologous chondrocyte implantation have demonstrated significant clinical improvement and good quality repair tissue five years after surgery. This procedure has been shown to be a safe and effective treatment for symptomatic, traumatic chondral knee defects, particularly involving the patellofemoral joint, as in this case. Therefore, autologous cultured chondrocyte implantation in the knee is likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 53-year-old female enrollee has requested authorization and coverage for autologous cultured chondrocytes implant knee. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient presents with a history of progressively worsening bilateral knee pain. Functional difficulty is reported in activities of daily living and recreational pursuits. She is status post bilateral knee arthroscopy, chondroplasty, synovectomy, and plica resection, and chondral biopsy on the right knee on 7/18/18. The surgeon reports left knee operative findings included a grade IV chondral defect in the lateral facet of the patella measuring 2 x 2 cm, and a grade III defect on the anterolateral trochlea measuring 5 x 5 mm. All defects had been debrided back to stable margins with Outerbridge grade I/II at the lesion borders. She subsequently underwent right knee surgery, including the matrix-induced autologous chondrocyte implantation procedure. Evidence of a recent, reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. Under consideration is a request for left knee matrix-induced autologous chondrocyte implantation. There is U.S. Food and Drug Administration (FDA) approval for the use of matrix-induced autologous chondrocyte implantation in this clinical setting. There is current peer-reviewed evidence indicating that matrix associated chondrocyte implantation is safe and effective for the treatment of full thickness cartilage defects in the knee, with no effect of the location of the defects or number of defects on study outcomes. In sum, autologous cultured chondrocyte implantation in the knee is likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 53-year-old female enrollee has requested authorization and coverage for autologous cultured chondrocytes implant knee. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. This patient has significant bipolar cartilage lesions in her knee in the patellofemoral joints bilaterally. There is a lack of evidence supporting autologous chondrocyte implantation for a bipolar lesion. Ogura and colleagues performed a study without a control group that addressed using autologous implantation for a bipolar lesion. However, without a control group, definitive conclusions cannot be drawn. The current standard would be a patellofemoral arthroplasty. Thus, autologous cultured chondrocyte implantation in the knee is not likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 25-year-old male enrollee has requested reimbursement for corneal crosslinking provided on 8/06/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting. The records document keratoconus and vision loss. Corneal collagen cross-linking is a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant. Furthermore, corneal collagen cross-linking for corneal ectasias fulfills an unmet need. There is a lack of other treatment options available to slow or halt disease progression. Therefore, corneal cross-linking provided on 8/06/18 was likely to have been more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 25-year-old male enrollee has requested reimbursement for corneal crosslinking provided on 8/06/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that Corneal cross-linking has been approved as a treatment of progressive (unstable) keratoconus. This patient was diagnosed with keratoconus and reported increasing blurriness in both eyes. In this case, the patient has two major risk factors suggesting that his keratoconus is likely to progress. Given his young age, he is likely to progress. Second, by history, he reports that his vision has declined in the last two years. There is a lack of other treatment options in this clinical setting. In sum, corneal cross-linking provided on 8/06/18 was likely to have been more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 25-year-old male enrollee has requested reimbursement for corneal crosslinking provided on 8/06/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the patient was diagnosed with keratoconus in April 2013.  On 5/13/14, his best corrected visual acuity was 20/40 in both eyes with manifest refraction. Corneal cross-linking has been approved by the U.S. Food and Drug Administration for keratoconus and post-refractive ectasia. The primary purpose of cross-linking is to halt the progression of corneal thinning and stiffen the cornea. Prior to this treatment, patients with keratoconus who failed medical treatment (glasses and contact lenses) and whose disease continued to progress would undergo surgical management with corneal transplantation. Although better designed randomized control trials and long-term data are still underway, there is mounting evidence of the benefit of this treatment in younger patients with keratoconus and evidence of disease progression. In this case, the records do not clearly document that this patient has evidence of progressive keratoconus as indicated by increasing keratometry values, change in best corrected visual acuity, contact lens intolerance, and corneal pachymetry measurements. Therefore, the superior efficacy of the services at issue has not been established. Thus, corneal cross-linking provided on 8/06/18 was not likely to have been more beneficial than other available treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 40-year-old female enrollee has requested reimbursement for cytogenomic constitutional microarray analysis performed on 6/14/17. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees recurrent miscarriages. The physician reviewer found that according to the American College of Obstetricians and Gynecologists (ACOG), approximately 50% of all causes of early pregnancy loss are due to fetal chromosomal abnormalities. For this reason, genetic testing is recommended, especially in women of advanced maternal age or following two or more miscarriages. Chromosomal microarray analysis is a method of measuring gains and losses of DNA throughout the human genome. This testing can identify chromosomal aneuploidy and other large changes in the structure of chromosomes that would otherwise be identified by standard karyotype analysis, as well as submicroscopic abnormalities that are too small to be detected by traditional modalities. Accordingly, the cytogenomic constitutional microarray analysis performed on 6/14/17 was medically necessary for evaluation of the patients medical condition. Based on the foregoing discussion, the testing at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 29-year-old female enrollee has requested authorization and coverage for Otezla 30 mg tablets. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriasis. The physician reviewer found the patients diagnosis of chronic plaque psoriasis requires systemic treatment. Psoriasis is a chronic inflammatory skin disease. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor (TNF) biologic therapies for the treatment of moderate to severe psoriasis have been a major clinical and research focus. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. On the other hand, Otezla does not increase the risk of malignancy, and it is approved by the U.S. Food and Drug Administration for treatment of psoriasis. Moreover, Otezla may be taken orally and is a therapeutic option for treatment of this patient. The physical limitations and risk of cancer/infection of injectable biologics, taken together with this patients family history of cancer, support Otezla for treatment of this patient.  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 Overturned

Summary Reviewer 


A 32-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 1b. 

 The physician reviewer found that 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 virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested treatment with Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection. Based on the foregoing discussion, 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 32-year-old female enrollee has requested reimbursement for bilateral breast magnetic resonance imaging (MRI) performed on 1/28/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who tested positive for BRCA1 mutation. The physician reviewer found that the limitations of mammography in the detection of breast cancer in patients with dense tissue have been well-documented. In patients with BRCA1 mutation, there is a markedly elevated lifetime risk of breast cancer exceeding 75%. MRI has been shown to be far superior to mammography in the detection of breast cancer. The medical evidence supports the services at issue in this clinical setting. Therefore, bilateral breast MRI performed on 1/28/18 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 32-year-old female enrollee has requested reimbursement for bilateral breast magnetic resonance imaging (MRI) performed on 1/28/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who tested positive for BRCA1 mutation. The physician reviewer found that patients who have a BRCA mutations have been shown to have an extraordinarily high incidence of both breast and ovarian carcinoma. As such, this patient has undergone a diligent screening regimen, interrupted only by her pregnancy. Breast MRI has an important role in both screening and diagnostic settings. The current medical evidence supports the services at issue in this clinical setting. In sum, bilateral breast (MRI) performed on 1/28/18 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 32-year-old female enrollee has requested reimbursement for bilateral breast magnetic resonance imaging (MRI) performed on 1/28/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who tested positive for BRCA1 mutation. The physician reviewer found that contrast-enhanced breast MRI is more sensitive for the detection of breast cancer in the high risk population than both mammography and ultrasound. Screening breast MRI is recommended in women with BRCA gene mutations, their untested first-degree relatives, and women with a lifetime risk of greater than 20%. The American Cancer Society, American College of Radiology, and Society of Breast Imaging all recommend annual screening MRI in high-risk patients. A common screening protocol is alternating MRI with mammography/ultrasound every six months. This patient has a known BRCA1 gene mutation and is therefore considered one of the highest risk populations for breast cancer. She is alternating mammography/ultrasound with MRI every six months. Due to pregnancy and subsequent breastfeeding, she was unable to obtain her annual screening MRI, which would have been due February 2017. Therefore, MRI was appropriately performed in January 2018 after the cessation of breastfeeding, according to her screening schedule. Thus, bilateral breast MRI performed on 1/28/18 was likely to have been of more efficacious than other modalities for 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 Upheld

Summary Reviewer 1

The patient is a 36-year-old male who is under evaluation for gastroesophageal reflux disease (GERD). The patient experiences severe sub-xiphoid pain with exercise or lying down to sleep. The patients symptoms typically occur when eating calorie rich food. The patient has some symptoms consistent with gastroparesis although his gastric emptying scan was normal. He has had an overall poor response to proton pump inhibitor (PPI) therapy. On manometry he has a low lower esophageal sphincter (LES) pressure with small-medium sized hiatal hernia. A pH study was borderline positive with a low DeMeester score. The patient has requested authorization and coverage for transoral incisionless fundoplication (TIF) with EsophyX device. The Health Insurer has denied this request as investigational. The requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. TIF is a minimally invasive treatment for GERD that is performed in the outpatient setting. In the medical literature, Wendling and colleagues reported in a recent systematic review that TIF appears to provide symptomatic relief with reasonable levels of patient satisfaction at short-term follow-up. However, the authors noted that a well-designed prospective clinical trial is needed to assess the effectiveness and durability of TIF as well as to identify the patient population that will benefit from this procedure. In sum, there is a lack of sufficient controlled data to show that TIF is non-inferior to fundoplication or that the procedure has long-term efficacy. For the reasons provided, the request for TIF with EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Based upon the information set forth above, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

The patient is a 36-year-old male with a history of heartburn and postprandial symptoms. The patients symptoms have reportedly been incompletely improved with proton pump inhibitor (PPI) therapy, or with ranitidine in combination with sucralfate. Per charting dated 1/27/16, an upper endoscopy demonstrated irregular Z-line, small hiatal hernia and chronic carditis. An esophageal manometry demonstrated normal motility with low lower esophageal sphincter (LES) pressures and minimal hiatal hernia. A 24-hour pH impedance off of PPI demonstrated a DeMeester score of 10.9 with symptom association probability (SAP) of 76%. The provider notes that the patient does not seem to have nocturnal reflux. On 3/7/16, ambulatory pH monitoring off acid blockers showed a composite DeMeester score of 30.1 with good symptom correlation with heartburn. An esophagogastroduodencoscopy (EGD) on 3/7/16 showed a histologically unremarkable upper gastrointestinal (GI) tract to the duodenum. The patient has requested authorization and coverage for transoral incisionless fundoplication (TIF) with EsophyX device. The Health Insurer has denied this request as investigational.  The request for TIF with EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patients acid reflux has been documented by pH testing, but the studies were performed off of acid suppression therapy. There is a lack of documentation provided to support that the patients reflux is refractory to optimally-dosed conventional acid suppression, nor that he has endoscopically-confirmed significant esophageal injury secondary to gastroesophageal reflux disease (GERD). Therefore, the request for TIF with EsophyX device procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Based upon the information set forth above, the requested procedure is 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.