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

Summary Reviewer 3


A 64-year-old female enrollee has requested placement of permanent sacral nerve stimulator performed on 12/09/14.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees fecal incontinence. The physician reviewer found in this patients case, the submitted records fail to establish the superior effectiveness of the services at issue.  The clinical records did not provide details regarding what treatments had been tried and failed for her condition.  Although the use of sacral nerve stimulation appears to hold promise in many patients with fecal incontinence, the records were insufficient to support the services at issue in this case.  Thus, the permanent sacral nerve stimulator provided on 12/09/14 was not likely to be of greater benefit than other available options.  Based upon the information set forth above, the services at issue were 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 1

A 47-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System. 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 sufficient support for the requested services in this clinical setting. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of obstructive sleep apnea. This trial demonstrated the hypoglossal nerve stimulator to be safe and effective in a small subset of patients with obstructive sleep apnea who have failed continuous positive airway pressure (CPAP) therapy, have nonconcentric airway collapse, an apnea-hypopnea index (AHI) between 20 and 50, and a body mass index (BMI) less than 32. With a BMI of 28.19, AHI of 21.2, and nonconcentric airway collapse, this patient meets the criteria. He has failed CPAP, which is the gold standard treatment for obstructive sleep apnea and is at risk for untoward cardiac sequelae of untreated obstructive sleep apnea. Therefore, hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System is likely to be more effective than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 47-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System. 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 the current medical evidence supports the requested services in this case. This patient has obstructive sleep apnea and has Friedman 3 tongue position. A drug induced sleep endoscopy showed no concentric collapse at velum. The patient has not been able to tolerate the continuous positive airway pressure (CPAP) device. The Inspire device has been approved by the U.S. Food and Drug Administration for the treatment of obstructive sleep apnea. This patient is a candidate for the Inspire device given his body mass index is less than 32, he has apnea-hypopnea index (AHI) of 21.2, and has no concentric collapse at the velum. In sum, hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System is likely to be superior over other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 47-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System. 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 the submitted documentation supports the requested services in this patients case. He has an apnea-hypopnea index of 21.1 and is unable to tolerate continuous positive airway pressure therapy. This patient meets clinical criteria for consideration of surgical management of his obstructive sleep apnea symptoms. Clinical studies of the use of hypoglossal nerve stimulation suggest that patients with a body mass index less than 32 benefit from this device. This patient meets this criteria, as his body mass index is 28.19. Thus, hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System is likely to be more efficacious than other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a 15-year-old male enrollee has requested authorization and coverage for Humatrope 24 mg cartridge. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for treatment of the enrollees idiopathic short stature. The physician reviewer found the submitted documentation supports the medical necessity of the requested medication in this patients case. According to the Pediatric Endocrinology Society guidelines, a trial of growth hormone therapy should be approved for children with otherwise unexplained short stature who pass growth hormone stimulation tests but who meet most of the following criteria: height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; growth velocity less than the 25th percentile for bone age; bone age more than two standard deviations below the mean for age; low serum IGF-1 and/or IGFBP-3; and/or other clinical features suggestive of growth hormone deficiency. Although this patient meets only some of the above criteria, he has been receiving growth hormone therapy since May 2016, with improvement in growth velocity. It is difficult to discern in retrospect how much of the improvement of his growth velocity is due to growth hormone therapy versus endogenous sex steroid production with progression in puberty. However, withdrawal of growth hormone therapy at this point in time, during mid-puberty, is not medically appropriate and may significantly compromise final adult height. Therefore, continuation of growth hormone therapy is medically necessary until epiphyseal fusion. All told, Humatrope 24 mg cartridge is medically necessary 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 Overturned

Summary Reviewer 


A 49-year-old female enrollee has requested authorization and coverage for hysterectomy. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees symptomatic fibroids. The physician reviewer found that there is support in the medical literature for the medical necessity of the requested procedure in this clinical setting. In this patients case, she has pain and heavy bleeding that continue to interfere with her quality of life. There are a number of surgical and non-surgical management options for symptomatic fibroids. This patient has already had a myomectomy and her symptoms are worsening. She is not a good candidate for estrogen containing medications, as she is a smoker.  In this patients case, the literature supports the hysterectomy as a treatment modality for symptomatic fibroids. Accordingly, hysterectomy is medically necessary for the treatment of this patient. Therefore, for the reasons stated above, the requested procedure 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 28-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees persistent asthma and shortness of breath. The physician reviewer found that to date the three initial trials of bronchial thermoplasty have demonstrated improved symptom control after the procedure was completed. The AIR trial examined 112 subjects with moderated to severe asthma and demonstrated improved control over the course of the one year follow-up (Cox, et al). The RISA study examined the safety of thermoplasty and found short term worsening in symptoms, but evidence of improved long term control of asthma (Pavord, et al). Finally, the AIR2 trial compared thermoplasty with a sham procedure and followed the patients out for 12 months as well (Castro, et al). Overall, the data supports the short- and long-term benefits of bronchial thermoplasty for patients who fail to improve despite maximal medical therapy. This patient is on an aggressive regimen and further the notes indicate that she is not a candidate for omalizumab. The patient has undergone an extensive evaluation and is on therapy for several associated conditions which could worsen her asthma control. Since these interventions have not ideally controlled her asthma, bronchial thermoplasty is the logical and appropriate next step in management and likely to be more beneficial than any available standard therapy. Based upon the information set forth above, the requested procedure 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 2


A 28-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees persistent asthma and shortness of breath. The physician reviewer found that this patient meets the established criteria for bronchial thermoplasty based on age, pulmonary function, severity of condition and treatment program. Her computed tomography (CT) scan showed diffuse mild bronchial wall thickening but no bronchiectasis which would contraindicate bronchial thermoplasty. Bronchial thermoplasty is a newer treatment for severe asthma, now included in GINA (Global Initiative for Asthma) guidelines. The American College of Chest Physicians also considers bronchial thermoplasty an important treatment option for adult patients with severe asthma who continue to be symptomatic despite maximal medical treatment. Wechsler and colleagues showed bronchial thermoplasty is an effective and safe therapy with reductions in exacerbations lasting to at least five years. While some studies have shown short-term increase in asthma morbidity, long lasting improvement appears to be the most common outcome. Consistent with this support, the requested bronchial thermoplasty is likely to provide this patient with greater benefits than any available standard therapy. Based upon the information set forth above, the requested procedure 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 3

A 28-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees persistent asthma and shortness of breath. The physician reviewer found that bronchial thermoplasty is a procedure that uses a bronchoscope probe/catheter to provide thermal energy to the smooth muscle of the airway. The tissue is heated to 65 degrees centigrade. There are three bronchoscopic procedures. The first treats the right lower lobe, the second the left lower lobe, and the third bronchoscopic procedure is for both upper lobes. The procedures are scheduled three weeks apart. This patients provider states the patient has a progressive decrease in the quality of life, but there is a lack of documentation that the use bronchial thermoplasty would improve the long-term functional outcome of the patients condition. Thus, the requested bronchial thermoplasty is not likely to provide this patient with an improved health outcome when compared with standard alternatives. 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 Overturned

Summary Reviewer 1

A 59-year-old female enrollee has requested reimbursement for HCMNext Reflex-Ambry genetic test performed on 10/2/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollee, who has a history of hypertrophic cardiomyopathy. The physician reviewer found that based on the records provided the patient has been diagnosed with hypertrophic cardiomyopathy by echocardiography. The patient also has a 22-year-old son.  In this circumstance, the use of genetic testing in the proband (patient) is supported in the medical literature in order to determine the presence of any gene defect that may be then tested for in the son and other family members who may be at risk.  If a gene mutation known to cause hypertrophic cardiomyopathy is identified in the proband, then this can be used as definitive screening of family members without the need for serial testing with less accurate imaging tests such as serial echocardiography or cardiac magnetic resonance imaging. Current guidelines recommend genetic screening of a proband with hypertrophic cardiomyopathy. As such, HCMNext Reflex-Ambry Genetics test on 10/2/17 was likely to have been more beneficial than the standard options available for evaluating this patient.

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 59-year-old female enrollee has requested reimbursement for HCMNext Reflex-Ambry genetic test performed on 10/2/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollee, who has a history of hypertrophic cardiomyopathy. The physician reviewer found that the documentation provided does not support the testing at issue was likely to have been more effective when compared to available standard methods of evaluating this patient. The patient did not complain of lightheadedness or palpitations and had no other non-invasive evaluation prior to genetic testing. There was no evidence provided that the genetic testing offered prognostic information. While the patient has evidence of hypertrophic cardiomyopathy by echocardiography, the provider calculated a 2.09% five year risk of sudden cardiac death and opined that she was not a candidate for prophylactic implantable cardioverter defibrillator placement. In spite of the positive results from the genetic testing for a pathogenic variant associated with a diagnosis of hypertrophic cardiomyopathy, the records provided for review do not support any change of the patients therapy based on these results. The patient was recommended for a one year follow up with the cardiologist provider which would indicate clinical stability.  Accordingly, HCMNext Reflex-Ambry genetic testing performed on 10/2/17 was not likely to have been more beneficial than the standard evaluation techniques available for treating this patient.

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.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 59-year-old female enrollee has requested reimbursement for HCMNext Reflex-Ambry genetic test performed on 10/2/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollee, who has a history of hypertrophic cardiomyopathy. The physician reviewer found that this patient has clinical features suggesting hypertrophic cardiomyopathy, a genetic disease that may lead to heart failure or sudden cardiac death. She had left ventricular septal hypertrophy by echocardiogram and a family history of sudden cardiac death. Based on current Heart Rhythm Society (HRS) and the European Heart Rhythm Association (EHRA) guidelines, genetic testing is recommended ( a class I indication) for any patient in whom a cardiologist has established a clinical diagnosis of hypertrophic cardiomyopathy based on the patients clinical history, family history and EKG/ECHO phenotype. This patient meets these guideline criteria. Genetic testing was medically indicated and confirmed the diagnosis. As such, the genetic testing at issue was within standard of care. Therefore, HCMNext Reflex-Ambry genetic test performed on 10/2/17 was likely to have been more efficacious than the available modalities for evaluating this patients medical condition.

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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 53-year-old female enrollee has requested authorization and coverage for Nerlynx 40 mg. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that Neratinib (Nerlynx) is U.S. Food and Drug Administration (FDA) approved for extended adjuvant treatment (as a single agent) of early-stage HER2 positive breast cancer (following adjuvant trastuzumab-based therapy). Neratinib has demonstrated improvements in recurrence rates when used in the adjuvant setting following treatment with single-agent trastuzumab, particularly in patients with HER2 positive tumors that are larger and estrogen receptor positive. There is a lack of data on the safety or efficacy of neratinib in patients whose adjuvant therapy included pertuzumab (Perjeta). The use of neratinib following adjuvant trastuzumab is usually limited to higher-risk (by stage), HER2 positive breast cancers. There is a lack of data for the benefit of neratinib in women who have received pertuzumab or T-DM1 as part of their neoadjuvant treatments. Use of neratinib in this setting is not supported by the National Comprehensive Cancer Network and is not considered a standard of care. This patient received pertuzumab in both the neoadjuvant and adjuvant setting. Therefore, Nerlynx 40 mg is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 54-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees persistent asthma.   The physician reviewer found that bronchial thermoplasty is not considered standard of care for the treatment of asthma. In a recent publication noting the safety of the procedure, there was no difference in forced expiratory volume 1 (FEV1), emergency department visits, or hospital admissions between the bronchial thermoplasty group and the control group (Thomson, et al). Also, one clinical trial with sham bronchial thermoplasty documented placebo efficacy (Castro, et al). In this case, the provider states the patient has a progressive decrease in quality of life, but there is no documentation that the use bronchial thermoplasty would improve the long-term functional outcome of the patients condition. Accordingly, the requested bronchial thermoplasty 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


A 54-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees persistent asthma.   The physician reviewer found the most important considerations in the use of bronchial thermoplasty are the proper selection of patients and ensuring an experienced qualified provider is performing the procedure. Bronchial thermoplasty has adequate data on long-term safety and effectiveness in patients with asthma in terms of demonstrating improvement in symptoms and reduction in exacerbations. On the basis of daily symptoms, frequent rescue medication use, interference with daily activities and frequent exacerbations, this patient meets criteria for severe persistent asthma. However, there is not adequate information provided to determine two important considerations in the treatment of asthma. First, the records do not document that alternate diagnoses have been ruled out. The appearance of infiltrates and adenopathy on the computed tomography (CT) may indicate a secondary cause of wheezing. Secondly, there was not information provided to exclude other asthma therapies such as omalizumab or mepolizumab based on IgE levels or eosinophil counts. All told, there is a lack of documentation supporting the requested bronchial thermoplasty 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 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.