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

Summary Reviewer 2
A 73-year-old male requested reimbursement for genetic testing performed on 9/26/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma.  The physician reviewer found that the patient is a 73-year-old male who was diagnosed with locally recurrent invasive squamous cell carcinoma, moderately, differentiated midline frontal, anterior and posterior, shave incision. A sample specimen was submitted for next generation sequencing using FoundationOne. The patient requested reimbursement for genetic testing performed on 9/26/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational.As noted by the National Comprehensive Cancer Network (NCCN), current therapy and achieved outcomes for metastatic lung cancer is not based on panel testing. In general, to demonstrate clinical utility of panel genetic testing such as FoundationOne, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. However, there is a lack of published trials demonstrating that use of genetic panel testing such as FoundationOne to direct treatment results in improved patient outcomes. The available literature on clinical utility consists of a small number of uncontrolled studies and non-randomized controlled trials that use imperfect comparators. This evidence is insufficient to make any conclusions on clinical utility. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the FoundationOne testing provided on 9/26/16 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 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 73-year-old male requested reimbursement for genetic testing performed on 9/26/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma.  The physician reviewer found that the patient is a 73-year-old male with a recurrent squamous cell carcinoma of the scalp diagnosed in 2016 and now with suspected dural invasion. Prior treatment has included multiple Mohs procedures, cetuximab, temsirolimus, and Avastin. His medical history is complicated by heart and kidney transplants for which he is on chronic suppression. FoundationOne testing was sent on 9/26/16 to help guide therapeutic decision making. The patient requested reimbursement for genetic testing performed on 9/26/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational.The National Comprehensive Cancer Network (NCCN) panel encourages participation in a clinical trial for patients with metastatic squamous cell carcinoma. FoundationOne testing helps guide eligibility for clinical trials and help determine eligibility for compassionate use of PDL-1 inhibitors should the tumor express molecular markers indicating likelihood of efficacy. This patients course has been complicated by the use of immunosuppressive medications for his heart and kidney transplant. Accordingly, the genetic testing performed on 9/26/16 was 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 services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 31-year-old male enrollee has requested reimbursement for respiratory sleep studies performed on 6/8/14, 6/17/14 and 6/19/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees sleep apnea. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. There was no documentation of hypersomnia. Hypersomnia is the cornerstone for a diagnosis of clinically significant sleep apnea. In addition, his Epworth Sleepiness score was normal at 4. There was no reported morning headache. The patient reported snoring and was slightly overweight. However, this is not an indication for a sleep study. Based on the medical records submitted and the peer-reviewed literature, the respiratory sleep studies performed on 6/8/14, 6/17/14 and 6/19/14 were not medically necessary for evaluation of the patients medical condition. 
For the reasons provided, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The parent of a four-year-old male enrollee has requested reimbursement for the polymerase chain reaction (PCR) testing and homocysteine testing performed on 6/4/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees risk for methylenetetrahydrofolate (MTHFR), Factor V Leiden, and homocysteine mutations. The physician reviewer found that in the evaluation of thrombophilia, providers frequently conduct MTHFR polymorphism testing, as it has been hypothesized that reduced enzyme activity of MTHFR leads to hyperhomocysteinemia which results in an increased risk for venous thromboembolism, coronary heart disease, and recurrent pregnancy loss. According to the American College of Medical Genetics and Genomics, recent meta-analyses have disproven an association between hyperhomocysteinemia and risk for coronary heart disease and between MTHFR polymorphism status and risk for venous thromboembolism (Hickey, et al). These findings have led the American College of Medical Genetics and Genomics to state that there is growing evidence that MTHFR polymorphism testing has minimal clinical utility and, therefore should not be ordered as a part of a routine evaluation for thrombophilia (Hickey, et al). For these reasons, the American Congress of Obstetricians and Gynecologists does not recommend the measurement of homocysteine or MTHFR polymorphisms in the evaluation of the etiology of venous thromboembolism (Lockwood, et al). In this case, the mother of the patient was found to have a homozygous A1298C mutation in MTHFR. However, it does not appear that this finding alone accounts for mothers recurrent deep venous thromboses during pregnancy. Moreover, the testing performed in this patient is not supported in the current peer-reviewed medical literature. All told, the PCR testing and homocysteine testing performed on 6/4/16 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

The parent of a four-year-old male enrollee has requested reimbursement for the polymerase chain reaction (PCR) testing and homocysteine testing performed on 6/4/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees risk for methylenetetrahydrofolate (MTHFR), Factor V Leiden, and homocysteine mutations. The physician reviewer found that the American College of Medical Genetics (ACMG) recommends against testing for MTHFR polymorphisms in any patients, including patients with relatives with known MTHFR polymorphisms. There is no risk associated with the A1298C polymorphism in the heterozygous or homozygous state. Further, it could have been predicted that this patient would have at least one copy of A1298C, as his mother is homozygous. The ACMG guideline indicates that testing of homocysteine is reasonable only in patients with two copies of the C677T polymorphisms, though this is not possible for this patient based on his mothers testing. The ACMG additionally has prepared guidelines on Factor V Leiden testing, which do not suggest testing for this patient. Accordingly, the PCR testing and homocysteine testing performed on 6/4/16 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

The parent of a four-year-old male enrollee has requested reimbursement for the polymerase chain reaction (PCR) testing and homocysteine testing performed on 6/4/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees risk for methylenetetrahydrofolate (MTHFR), Factor V Leiden, and homocysteine mutations. The physician reviewer found that although this patients mother experienced blood clots at an early age and in unusual places, the patient himself is not reported to have thrombosis. The American College of Medical Genetics (ACMG) practice guidelines regarding genotyping of MTHFR do not support testing in this clinical setting. Studies of MTHFR have focused on a wide varieties of conditions, including vascular disease, neural tube defects, mental illness, autism, and cancer. While some studies have found associations, other studies have found no association. Ultimately, the ACMG found that there is insufficient evidence of clinical utility of MTHFR polymorphism testing. The mother reports that she tested negative for the Factor V Leiden mutation. Thus, testing this patient who is asymptomatic was not indicated, particularly in light of the fact that the only person in the family with thrombosis has tested negative. In summary, the PCR testing and homocysteine testing performed on 6/4/16 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 63-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 6/11/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the review of the submitted documentation and relevant literature supports the services at issue in this clinical setting. While there is a lack of long-term studies proving increased survival rates when tomosynthesis is used as a mammographic tool the addition of the technique to both screening and diagnostic mammography has gained worldwide popularity among providers due to the advantage the technique offers by eliminating overlapping dense glandular tissue from being confused with mass or architectural distortion which in turn could indicate neoplasm. The addition of the technique has reduced callbacks and increased detection of small cancers. Thus, the use of tomosynthesis in this case helped eliminate the concern of underlying malignancy. Therefore, the digital breast tomosynthesis performed on 6/11/15 was 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 services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 63-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 6/11/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the breast tomosynthesis at issue was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Ciatto and colleagues investigated the effect of integrated two-dimensional (2D) and three-dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Thus, the literature does support the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate. Additionally in this case, the tomographic images were particularly helpful in resolving the left breast asymmetry as normal tissues, which was the lesion in question. Based on the support in the medical literature and the clinical documentation submitted for review, the use of breast tomosynthesis was 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 services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 63-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 6/11/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor. In this particular case, the use of tomosynthesis was as a problem solving tool. On her initial mammogram, only two views of each breast were obtained.  It was after a questionable abnormality was detected that she was recalled for additional imaging including a breast sonogram and a tomosynthesis exam.  This is an appropriate use of tomosynthesis.  In addition, she has heterogeneously dense breasts.  For the reasons provided, the digital breast tomosynthesis performed on 6/11/15 was 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 services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 




A 53-year-old male enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS). The Health Insurer has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees major depressive disorder. The physician reviewer found that TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. The procedure is well tolerated with fewer barriers and side effects than electroconvulsive therapy. TMS is U.S. Food and Drug Administration (FDA) approved and supported by the American Psychiatric Association (APA) for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. Further, the APA made no mention of pre-requisite psychotherapy. Thus, the standard of care does not require a certain course of psychotherapy prior to TMS. In this case, the patient remains symptomatic despite first-line medications and psychotherapy. Considering the medical records, endorsement from the APA and the expanding peer-reviewed literature base, TMS represents a safe, appropriate treatment consistent with good medical practice that is reasonably expected to improve the patients condition and prevent a more serious episode of illness. As such, the requested TMS is medically necessary for treatment of the patients major depressive disorder. Therefore, the requested service is medically necessary 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 54-year-old male has requested reimbursement for Anser VDZ test provided on 7/17/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found that clinically, there did not appear to be any connection between the medication and the new onset neurologic symptoms. Performing the Anser VDZ testing would not clarify whether there was a relationship, as there is no question that the patient was exposed to the drug for a long period with each infusion. This is not antibody mediated. Therefore, the presence of antibody would also not be helpful to know. Finally, there is a lack of support for the use of Anser VDZ testing to optimize reactive treatment though targeted drug measurement.  All told, Anser VDZ test provided on 7/17/17 was not likely to have been superior over 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 2

A 54-year-old male has requested reimbursement for Anser VDZ test provided on 7/17/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found that Entyvio (vedolizumab) is a humanized monoclonal antibody. This medication is specifically indicated for adults with moderately to severely active ulcerative colitis or Crohns disease who have had an inadequate response with, lost response to, or were intolerant to a tumor necrosis factor blocker or immunomodulator; or had an inadequate response with, were intolerant to, or demonstrated dependence on corticosteroid. Entyvio is indicated to induce and maintain clinical response/clinical remission, achieve corticosteroid-free remission and improve the endoscopic appearance of the mucosa. Contemporary literature supports that vedolizumab response, and its long-term effectiveness, are not based on drug-antibody titers, but on clinical factors.  At this time, it has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. In this patients case, he was not experiencing significant gastrointestinal symptomatology at the time of the testing. In sum, the records fail to establish the superior efficacy of the Anser VDZ test provided on 7/17/17. 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 54-year-old male has requested reimbursement for Anser VDZ test provided on 7/17/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found that there is insufficient medical evidence to support the effectiveness of Anser VDZ compared with conventional courses of action in the management ulcerative colitis. The published studies including the use of anti-Entyvio antibodies and serum levels are small, retrospective, and/or observational rather than controlled (in regards to the study of using Entyvio levels and anti-Entyvio antibody levels) in nature, preventing firm conclusions about cause and effect. Additionally, the antibodies can be transient. Controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with ulcerative colitis compared with conventional management. For these reasons, Anser VDZ test provided on 7/17/17 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 Overturned

Summary Reviewer 


A 31-year-old female enrollee has requested authorization and coverage for Xifaxan. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees irritable bowel syndrome. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested medication. Xifaxan is approved by the U.S. Food and Drug Administration (FDA) for the treatment of IBS. According to the study by Pimentel and colleagues, Among patients without constipation, treatment with rifaximin for two weeks provided significant relief of bloating, abdominal pain, and loose or watery stools. In addition, both the American Gastroenterological Association guideline and the American College of Gastroenterology guideline reviewed the data on the randomized controlled trials for rifaximin, and found that there was moderate evidence that it was effective. In sum, Xifaxan is supported by evidence-based literature, and the medical necessity of the requested medication has been established in this patients case. For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.