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

Summary Reviewer 1

A 56-year-old male enrollee has requested authorization and coverage for proton treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees tumor of the hypopharynx. The physician reviewer found that there is limited, evidence based, peer reviewed literature on the effectiveness of proton therapy over other forms of treatment in this clinical setting.  A 2014 review article by Holliday and Frank cited only one study (of 29 patients) of proton therapy for oropharyngeal cancer, and none are cited for hypopharyngeal cancers. Data on proton therapy for hypopharyngeal cancers are scant.  Likewise, there is scant data which compares outcomes with proton therapy versus intensity modulated radiation therapy (IMRT). While preliminary dosimetric data suggests that proton therapy may be better at sparing pharyngeal constrictor muscles spinal cord, parotid glands, larynx, and brainstem whether dose reduction to any of these structures (beyond what IMRT can achieve) results in any benefit in clinical outcome is unknown. There is not enough studies that definitively show that proton therapy (in general) affords benefit over conventional radiation therapy.  The most recent National Comprehensive Cancer Network guidelines (v2.2016) do not address proton therapy for pharyngeal cancers and explicitly state that the role of proton therapy is being investigated for ethmoid and maxillary sinus cancers. At this time, further clinical data through prospective clinical trials are needed regarding cases in which the target is the primary volume located near critical structures. For this patient, there is no documentation that IMRT would result in an unacceptable plan. Currently, there are insufficient data to recommend proton treatment for routine head and neck radiation therapy outside of clinical trials. In summary, proton treatment is not likely to be superior to IMRT. Therefore, 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


A 56-year-old male enrollee has requested authorization and coverage for proton treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees tumor of the hypopharynx. The physician reviewer found Currently, that there is a lack of clinical data in the medical literature to indicate the superior efficacy of the requested services when compared to conventional treatment options. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy (IMRT).  A recent comparative analysis by Sio and colleagues found no significant difference in symptom burden in the acute and chronic phases of treatment with proton therapy compared to photon therapy for head and neck cancer. Also, the ASTRO emerging technology committee report on proton therapy specifically states that there is insufficient data to recommend proton beam therapy for routine head and neck radiation therapy outside of clinical trials, (Allen, et al). Moreover, there is a lack of level I evidence to support the use of proton therapy for the treatment of head and neck cancer.  The patients previous history of treatment with radioactive iodine does not preclude the use of standard treatment with photons. Therefore, proton therapy is not likely to be more effective than standard therapy in the treatment of this patients medical condition. 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 56-year-old male enrollee has requested authorization and coverage for proton treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees tumor of the hypopharynx. The physician reviewer found that in this clinical setting, there is a lack of published literature that compares clinical outcomes of proton beam radiotherapy to standard photon techniques. Consensus group guidelines do not support the use of proton therapy in this setting. Currently, proton therapy for head and neck cancer is being evaluated in National Cancer Institute sponsored trials. However, there is currently insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit beyond conventional radiation therapy. As such, proton therapy is not likely to be superior to the standard options available for treatment of this patients medical condition. Therefore, 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 28-year-old female enrollee has requested reimbursement for the treatment of dry eye performed on 6/02/15 (codes 68761, 83861 and 92285).  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees dry eyes. The physician reviewer found there is sufficient support for the services at issue in this patients case.  The patients dry eye syndrome has not responded to the usual medical therapies, including Restasis drops.  Her provider previously recommended use of artificial tears, omega-3 fatty acid supplements, lid hygiene twice daily and sleeping with a humidifier.  The use of punctum plugs is the next logical therapeutic regimen.  All told, treatment of dry eye performed on 6/02/15 was medically indicated for the treatment of this patient.  Therefore, the services at issue were 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 68-year-old female enrollee has requested reimbursement and prospective authorization and coverage for epidural injections from 6/06/16 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 medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient has extruded disc material as well as a disc protrusion.  These structural defects are not going to be altered by epidural steroids.  The patient has spinal stenosis, and the medical literature has shown that epidural steroid injections do not alter the course of the underlying pathology.  Radcliff and colleagues compared patients with lumbar spinal stenosis who received epidural steroid injections with patients who did not receive epidural injections during the first three months of the study.  The authors noted a worse outcome in the steroid treated group.  The current medical evidence does not support the services at issue in this clinical setting.  All told, epidural injections from 6/06/16 forward were not and are not medically indicated for the treatment of this patient.  Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 65-year-old male enrollee has requested reimbursement for gene testing provided on 9/26/18. 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 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 as either class 1 or 2, with class 2 melanomas having a significantly higher rate of recurrence than class 1. Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma class, in patients who have undergone sentinel node biopsy. Berger reported on 156 cases, but there was insufficient follow-up to determine the real value of the assay. 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 assay can be used to make clinical decisions. Therefore, gene testing provided on 9/26/18 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 65-year-old male enrollee has requested reimbursement for gene testing provided on 9/26/18. 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 had an early stage melanoma. The National Comprehensive Cancer Network guidelines state 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. 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. In sum, gene testing provided on 9/26/18 was not likely to have been more effective than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 65-year-old male enrollee has requested reimbursement for gene testing provided on 9/26/18. 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 DecisionDx-Melanoma 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 provided on 9/26/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 22-year-old male enrollee has requested reimbursement for outpatient behavioral health services provided from 1/01/16 through 1/05/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found THE submitted documentation fails to demonstrate the medical necessity of the services at issue.  On 12/22/15, the patients mood was stable, with no anxiety or depression.  He was sleeping well and denied cravings.  Therapeutically, he was focused on the conflicted relationship between his mother and grandmother.  On 1/01/16, the patient was described as insightful and motivated.  He was actively participating in his treatment.  His urine drug screen was negative.  He was medication adherent, which included quetiapine for insomnia.  He had good support from his grandmother.  In addition to his relapse prevention efforts, the patient was exploring his characterological organization and consolidating the grief from the death of his stepfather.  He was addressing long-term issues, but there was no evidence of an acute psychiatric syndrome, poorly controlled addictive illness or concerning environmental circumstances.  Further, the medical records did not include several documents critical to the review process, for example a psychiatric evaluation, psychosocial assessment, multidisciplinary treatment plan or interpretative summary.  In the absence of said documents, which typically detail the current status and impact of the illness, analyze the burden of relevant psychosocial stressors, review the outcome of prior interventions and articulate the need for the particular placement, the documentation does not establish that the treatment setting in dispute would have been more likely to improve the patients condition, prevent a more serious episode of illness or reduce morbidity than well-orchestrated community-based programming in a sober living environment.  All told, outpatient behavioral health services provided from 1/01/16 through 1/05/16 were not medically indicated for the treatment of this patient.  Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 41-year-old male enrollee has requested authorization and coverage for the LINX device. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found the request services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Although, the LINX reflux management system is U.S. Food and Drug (FDA) approved it has not been demonstrated to be superior to optimal medical therapy or a standard reflux operation in controlled trials. The evidence to date has been derived from open label studies which have used patients as their own controls. In addition, dysphagia is a common adverse side effect of the procedure and can lead to long term dissatisfaction from the patient's perspective. Therefore, the patients request for the LINX device is not supported as 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 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 41-year-old male enrollee has requested authorization and coverage for the LINX device. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found according to Lipham and colleagues, Sphincter augmentation with the LINX Reflux Management System provided long-term clinical benefits as demonstrated by reduced esophageal acid exposure, improved GERD-related quality of life, and cessation of dependence on PPIs, with minimal side effects. Patients with inadequate symptom control with acid suppression therapy may benefit from treatment with sphincter augmentation. The LINX device is U.S. Food and Drug Administration (FDA) approved for patients diagnosed with GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. In this case, the patient presents with GERD based on pH recording. His GERD has proven refractory to medical management, and thus he is expected to benefit from anti-reflux procedures, specifically the LINX device. In addition, the patient does not have any contraindications such as large hiatal hernia, esophageal dysmotility, Barrett's esophagus or cancer. Therefore, the requested services are 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 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 41-year-old male enrollee has requested authorization and coverage for the LINX device. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found the LINX device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The LINX device, which is U.S. Food and Drug Administration (FDA) approved, is laparoscopically implanted around the esophagus at the esophagogastric junction to mechanically augment the function of the lower esophageal sphincter (LES) for the treatment of GERD. LINX has shown efficacy up to four years in the reduction of the amount of pathologic esophageal acid exposure (Lipham, et al). A multi-institutional, non-randomized, prospective case series of 100 patients by Ganz and colleagues evaluated patients before and after sphincter augmentation with a magnetic device. The authors found exposure to esophageal acid decreased, reflux symptoms improved, and use of proton-pump inhibitors decreased. Based on the minimal invasive nature of the procedure, documented safety and efficacy data in multiple studies, and FDA approval, the requested services are 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 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 62-year-old male enrollee has requested reimbursement for long term acute care provided from 10/30/18 through 1/11/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that rehabilitation therapy services can be delivered in a wide variety of settings across the care continuum. Post-acute settings differ in the types of available rehabilitation therapies, intensity of therapy, and the level of medical and nursing support. Long-term acute care hospitals offer physical and occupational therapy, 24-hour skilled nursing care and a clinician available 24 hours per day. The medical providers are able to care for active/ongoing medical conditions requiring a clinician-level care (e.g., ventilator-dependent). The long-term acute care hospital setting is considered when the patients need for nursing and rehabilitative services are such that only an inpatient long-term acute care hospital setting can meet the requirements, and the expected length of stay is greater than 25 days. In this case, the documentation does not support that the patient required complex medical treatment (e.g., multiple and prolonged intravenous therapies; monitoring of significantly medically active conditions requiring clinical assessment six or more times a day; multiple and frequent intervention of at least six or more times a day, like ventilator management, cardiac monitoring, complex wound care for multiple wounds stages 3 and above; and the need for specialized high-tech equipment like cardiac monitors, on-site dialysis, or surgical suites) as of 10/30/18. The patient did not require services at the long-term acute care hospital setting that were not available at the acute care hospital or the skilled nursing facility. The requested treatments were not medically necessary at the long-term acute care hospital level of care from 10/30/18 through 1/10/19. Although the patient required hemodialysis, nutrition via a feeding tube and continued wound care, he was medically stable as of 10/30/18 and could have received services at a lower level of care. Therefore, long-term acute care provided from 10/30/18 through 1/11/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The patient is a 58-year-old male with chronic hepatitis C virus, genotype 1b. The documentation submitted for review indicates he has early stage disease. Fibrospect II testing on 2/13/14 revealed a Metavir score of F0-F1. The patients provider recommends treatment with Viekira Pak. Thus, the patient is requesting authorization and coverage for Viekira Pak. The Health Insurer has denied the requested medication as not medically necessary. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. According to the American Association for the Study of Liver Diseases (AASLD) recommendations for treating hepatitis C, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Denying treatment for patients with early stage hepatitis C is not supported by the peer-reviewed literature. Thus, the recommendation is not deny patients treatment if they have early stage disease, but to provide treatment to avoid complications from advanced disease, including liver failure and extrahepatic complications. AASLD/IDSA guidelines recommend Viekira Pak, a daily fixed-dose combination of paritaprevir (150 mg)/ritonavir (100 mg)/ombitasvir (25 mg) plus twice-daily dosed dasabuvir (250 mg) for 12 weeks for treatment-naive patients with HCV genotype 1 infection. For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.