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

Summary Reviewer 2

A 43-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 2/14/18. 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 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. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. In sum, DecisionDx-Melanoma testing performed on 2/14/18 was not likely to have been more efficacious 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.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 43-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 2/14/18. 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 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 to 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 for 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, DecisionDx-Melanoma testing performed on 2/14/18 was not 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 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 59-year-old female with listed diagnoses of inflammatory polyarthropathy, osteoarthritis and fibromyalgia. She has been treated with multiple medications, including prednisone, sulfasalazine, Humira, ibuprofen and Toradol. The physician reviewer found that the submitted documentation fails to support the medical necessity of the requested medication in this clinical setting. This patient reports pain in her back, hands and feet, as well as multiple soft tissue areas. She has been treated with multiple medications to date, all of which have either resulted in side effects or a lack of response. The available medical records do not document objective findings to support the presence of an inflammatory arthritis. There is no documentation of synovitis on physical examination, nor is there documentation of radiologic studies with findings consistent with inflammatory disease. On the basis of this lack of documentation, the requested medication is not medically indicated. Additionally, there is a lack of evidence
supporting the use of H.P. Acthar Gel in fibromyalgia. Therefore, H.P. Acthar 80 unit/mL Gel is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 58-year-old male enrollee has requested reimbursement for knee arthroscopy performed on 8/27/19. 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 there is a lack of support for the services at issue in this clinical setting. The Health Insurer covered the arthroscopy with partial medial meniscectomy and chondroplasty, but did not cover the synovectomy as there was no documentation of rheumatoid arthritis, pigmented villonodular synovitis, or other condition necessitating the synovectomy. In reviewing the medical literature pertaining to performing synovectomy for mild osteoarthritis, although it is supported in rheumatoid arthritis or pigmented villonodular synovitis, debridement of the synovium in mild osteoarthritis is not supported. As such, performance of synovectomy in this case was not medically necessary. Therefore, CPT 29876 provided on 8/27/19 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 45-year-old male enrollee has requested authorization and coverage for hybrid artificial disc replacement at L4-5 and fusion at L5-S1 (CPT codes 22558, 22851, 22585, 22845, 20930, 63090, 63091 and 77003). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The evidence based peer-reviewed literature does not support single-level artificial disc replacement in the setting of multilevel lumbar degenerative disc disease. In this case, the patient presents with low back pain radiating into the posterolateral left lower extremity to the foot. Clinical exam findings documented a normal neurologic presentation. There is imaging evidence of L4-5 and L5-S1 spondylosis, grade 1 retrolisthesis at L5-S1, Modic type 1 endplate changes, and mild bilateral neuroforaminal narrowing. A discogram was reportedly positive at L4-5 and L5-S1, but outcomes have not been found to be consistently reliable for the low back based upon recent studies (Eck, et al). In addition, a disc replacement adjacent to a fused spinal segment would represent a hybrid-type complex/construct of which there are a lack of long-term medical literature studies available. Therefore, the requested hybrid artificial disc replacement at L4-5 and a fusion at L5-S1 is not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. 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 45-year-old male enrollee has requested authorization and coverage for hybrid artificial disc replacement at L4-5 and fusion at L5-S1 (CPT codes 22558, 22851, 22585, 22845, 20930, 63090, 63091 and 77003). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. After implantation of metal and metal methylmethacrylate devices in the knee and hip, it has been demonstrated that the patients are exposed to particulate debris. This particulate debris consisting of abrasive wear and adhesive contact wear between the components of the device elicit a chronic inflammatory reaction including a giant cell tissue response. The effect of this exposure may vary from patient to patient but all patients will be exposed to the consequences of wear. Moreover, fusion at the L5-S1 level is not likely to effectively eliminate chronic inflammation with pro-inflammatory cytokines mediating the patients ongoing experience of lumbosacral regional pain. The extent of neural foraminal stenosis at L5-S1 is minimal based on two separate MRI studies performed. The clinical examination does not demonstrate motor deficits or sensory pattern changes beyond pain changes, and there is no definite evidence for spinal nerve root compromise. In this clinical setting, ongoing conservative management and continued observation is likely be more beneficial than surgical treatment plans. Accordingly, the request for hybrid artificial disc replacement at L4-5 and fusion at L5-S1 (CPT codes 22558, 22851, 22585, 22845, 20930, 63090, 63091 and 77003) are 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 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 45-year-old male enrollee has requested authorization and coverage for hybrid artificial disc replacement at L4-5 and fusion at L5-S1 (CPT codes 22558, 22851, 22585, 22845, 20930, 63090, 63091 and 77003). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found the request for hybrid artificial disc replacement at L4-5 and fusion at L5-S1 (CPT codes 22558, 22851, 22585, 22845, 20930, 63090, 63091 and 77003) are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. According to the North American Spine Society guidelines, lumbar artificial disc replacement is indicated as an alternative to lumbar fusion for patients with discogenic low back pain with advanced single level disease. In this case, the patient has multi-level degenerative disc disease confirmed on imaging. As such, the requested services have not been established 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 28-year-old female enrollee has requested reimbursement for substance use residential treatment center services provided from 1/23/17 through 2/10/17. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the substance use residential treatment center services provided from 1/23/17 through 2/10/17 were not medically necessary for treatment of the patients medical condition. Due to the lengthy history of substance use, a residentially based detoxification and preliminary introduction to chemical dependency treatment was safe, appropriate and consistent with good medical practice. Although addiction specialty services remained indicated, the clinical documentation does not demonstrate the medical necessity of treatment in a 24-hour supervised setting as of 1/23/17. By 1/22/17, the patient embraced recovery principles and was both active in treatment and motivated for sobriety. She was not experiencing withdrawal, or significant medical or psychiatric symptoms. She had a supportive family and a safe home environment. She had no prior history of chemical dependency treatment in a less restrictive setting such as anti-craving medication, community programming, outpatient specialty care, intensive outpatient services or partial hospitalization. In sum, there is a lack of evidence to suggest that comprehensive, evidence-based services provided in a less restrictive treatment setting would have been insufficient. Thus, the services at issue were not medically necessary for treatment of the patients medical condition. 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 Upheld

Summary Reviewer 1

A 34-year-old female enrollee has requested reimbursement for the gene test provided on 3/17/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for heart disease. The physician reviewer found that this patient presents with no reported history of cardiovascular disease. Her BMI is elevated and she has a history of vitamin D deficiency and hypothyroidism with no reported history of diabetes with a normal fasting glucose. Her baseline standard lipid profile shows a total cholesterol under 200 and mildly low high density lipoprotein (HDL), normal non-HDL cholesterol and triglycerides, with a borderline high low density lipoprotein (LDL) cholesterol of 140. She is not a candidate for consideration of statin therapy based on current risk parameters and the current lipid profile (Goff, et al; Stone, et al). There is no significant data that in a patient with this low standard risk profile, and in the absence of established cardiovascular disease or other significant risk factors for coronary artery disease at her age, that advanced lipid profile testing will add further clinically actionable information to the cardiovascular risk assessment or change the treatment strategy (Greenland, et al; Goff, et al). Thus, the gene test provided on 3/17/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 34-year-old female enrollee has requested reimbursement for the gene test provided on 3/17/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for heart disease. The physician reviewer found that the records provided for review document that this patient underwent advanced lipoprotein testing. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including Lp-PLA2, sub-classifications of low density lipoprotein (LDL), high density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine (Greenland, et al; Stone, et al). Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis (Lonn; Toole, et al). All told, the gene test provided on 3/17/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 34-year-old female enrollee has requested reimbursement for the gene test provided on 3/17/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for heart disease. The physician reviewer found that while some providers have advocated for routine use of advanced lipoprotein analysis, the most recent guidelines from the American College of Cardiology (ACC) do not support testing in this clinical setting. Rather, the guidelines recommend standard lipid profile testing and standard risk factor assessment to determine risk and management of future heart disease. This patient did not present with a history of cardiovascular disease or an increased risk of cardiovascular disease. For these reasons, the gene test provided on 3/17/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 31-year-old female enrollee has requested authorization and coverage for rituximab injection therapy. The Health Insurer has denied this request indicating that the requested therapy is considered investigational for treatment of the enrollees multiple sclerosis, relapsing-remitting. The physician reviewer found that rituximab is a monoclonal antibody therapy that has been utilized on an off-label basis for patients who have not responded to traditional multiple sclerosis (MS) therapies. Although rituximab is considered off label therapy for MS, results from the two rituximab MS trials were promising.  In a trial involving 439 patients with RRMS, those receiving rituximab experienced substantially fewer relapses and developed 92% fewer enhancing magnetic resonance imaging (MRI) lesions during the 48 weeks of the trial than those receiving placebo. In a trial involving patients with primary progressive MS, fewer people in the rituximab group (30.2%) experienced disability progression than in the placebo group (38.5%) after 96 weeks. Although the difference was within a range that might have occurred by chance, preplanned subgroup analysis detected a clear benefit for younger people and people with inflammatory MRI lesions. Furthermore, current trials have shown positive results. Based upon the information set forth above, the requested therapy is likely to be more effective 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 31-year-old female enrollee has requested authorization and coverage for rituximab injection therapy. The Health Insurer has denied this request indicating that the requested therapy is considered investigational for treatment of the enrollees multiple sclerosis, relapsing-remitting. The physician reviewer found the current medical evidence does not support the superior efficacy of rituximab injection therapy for treatment of the patients medical condition. The use of rituximab in the treatment of relapsing remitting multiple sclerosis has not been demonstrated in randomized studies to have effectiveness in the treatment of multiple sclerosis relative to disability progression.  The Cochrane database representing a meta-analysis review has concluded that there is no demonstration of efficacy of this treatment. Based upon the information set forth above, the requested therapy is not likely to be effective 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 3


A 31-year-old female enrollee has requested authorization and coverage for rituximab injection therapy. The Health Insurer has denied this request indicating that the requested therapy is considered investigational for treatment of the enrollees multiple sclerosis, relapsing-remitting. The physician reviewer found that although rituximab should not be considered a first line therapy for patients with relapsing remitting MS, there is sufficient medical literature supporting its use, benefit, and safety in patients with refractory MS. In this particular case, the patient has failed multiple first line therapies for treatment of her medical condition.  In addition, she has responded well to a prior treatment of rituximab and had no significant side effects with this medication.  Undertreated MS can cause significant morbidity and potentially early mortality.  As such, the use of rituximab in this particular case is medically reasonable.  Based upon the information set forth above, the requested therapy is likely to be superior than any available standard therapy for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 58-year-old female enrollee has requested reimbursement for MammaPrint testing performed on 1/21/14. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for the evaluation of the enrollees breast cancer. The physician reviewer found the testing provided on 1/21/14 was not likely to be more effective for this patient than other available treatment options. The National Comprehensive Cancer Network (NCCN) guidelines state MammaPrint is approved by the [U.S. Food and Drug Administration] FDA to assist in assignment of women with ER-positive or ER-negative breast cancer into a high versus low risk for recurrence, but not for predicting benefit from adjuvant system therapy. NCCN guidelines further state that studies using MammaPrint as a prognostic or predictive tool are too small and/or retrospective in nature. In sum, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 58-year-old female enrollee has requested reimbursement for MammaPrint testing performed on 1/21/14. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for the evaluation of the enrollees breast cancer. The physician reviewer found currently, OncotypeDx is the standard of care to determine recurrence risk and need for chemotherapy in women with early stage breast cancer (Foukakis and Bergh; Harris, et al). MammaPrint (or the Amsterdam 70 gene profile) offers prognostic information and is U.S. Food and Drug Administration (FDA) approved. However, there are low quality data to show MammaPrint has clinical utility. At present OncotypeDx is considered the standard of care and MammaPrint cannot be considered a more beneficial test. For the reasons provided, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.