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

Summary Reviewer 2

A 51-year-old male has requested reimbursement for gene expression profiling performed on 5/14/17. 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 there is a lack of support for the services at issue in this clinical setting. There is a lack of evidence from the literature that tailored follow-up according to these test results has an impact on long-term outcomes. Furthermore, prospective randomized studies to determine recurrence risk is lacking for this test. The medical evidence has not determined the superior efficacy of the services at issue. Thus, gene expression profiling performed on 5/14/17 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 51-year-old male has requested reimbursement for gene expression profiling performed on 5/14/17. 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 has an early stage melanoma. The National Comprehensive Cancer Network (NCCN) guidelines states that 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 this testing was not likely to have altered treatment and surveillance recommendations. In sum, the superior effectiveness of gene expression profiling performed on 5/14/17 has not been established. 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 Overturned

Summary Reviewer 1


A 53-year-old female enrollee has requested reimbursement for PathFinder TG testing (84999) performed on 7/30/14.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found current Guidelines from the American Gastroenterological Association Institute do not mention the use of molecular markers for the management of suspicious pancreatic cysts. A recently published technical review by the American Gastroenterological Association of the diagnosis of pancreatic cysts states that routine use cannot be supported at this time.  At this time, although molecular testing is encouraging, further validation is needed.  All told, PathFinder TG testing (84999) performed on 7/30/14 was not likely to have been of greater benefit than other modalities.  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 Overturned

Summary Reviewer 2


A 53-year-old female enrollee has requested reimbursement for PathFinder TG testing (84999) performed on 7/30/14.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found PathFinder TG analysis is an analysis of DNA, and mutations of DNA, in a cellular population.  It has been used in patients with cancer of unknown primary, to identify the tissue of origin of the cancer.  In such situations, its use is still controversial and has been useful in only a very limited number of individuals.  Another use of the this test is in the analysis of pancreatic cysts, in an effort to determine if they are truly benign, or whether they contain elements that are moving towards a malignant expression, which would require consideration of surgical therapy.  The medical literature has documented the validity of the use of this assay in this clinical setting.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 53-year-old female enrollee has requested reimbursement for PathFinder TG testing (84999) performed on 7/30/14.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the differential diagnosis of pancreatic cysts includes pseudocysts, simple cysts, and cystic neoplasms.  The latter category represents cancer and requires aggressive surgical resection.  Discriminating between benign and neoplastic lesions is complicated, and current technology is limited.  Esophagogastroduodenoscopy and esophageal ultrasound are important for surveillance, but clinical observation is not definitive.  Pathology is required.  An endosonogram combined with tumor marker analysis on sampled cystic fluid can add to the sensitivity of diagnosing neoplastic disease, but it does not to the degree necessary to determine which patients require surgery. There is sufficient support for the services at issue in this clinical setting.  The current standard approach of fluid cytology is inadequate to determine the management in every patient.  In this patients case, PathFinder TG testing performed on 7/30/14 was likely to have been of greater benefit than other options for evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 63-year-old female enrollee has requested reimbursement for the Prolia injection performed on 11/21/14. The Health Insurer has denied this request indicating that the services at issue were investigational for treatment of the enrollees medical condition. The physician reviewer found the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Denosumab (Prolia) is a fully human monoclonal antibody which has been approved for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone (McClung, et al). Prolia is U.S. Food and Drug Administration (FDA) approved for the treatment of postmenopausal osteoporosis in women at a high or increased risk of fracture who have failed or are intolerant to other available osteoporosis therapy. Fractures are the most dangerous aspect of osteoporosis, which can lead to acute and chronic pain (Old and Calvert). In this case, the patient failed bisphosphonate therapy (Actonel). As such, the Prolia injection provided on 11/21/14 was likely to be a more beneficial treatment than standard medical therapy in this clinical setting. Based upon the information set forth above, the services at issue were 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 63-year-old female enrollee has requested reimbursement for the Prolia injection performed on 11/21/14. The Health Insurer has denied this request indicating that the services at issue were investigational for treatment of the enrollees medical condition. The physician reviewer found the Prolia injection performed on 11/21/14 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is data to support use of Prolia in this clinical setting. Denosumab has been associated with a reduction in the risk of vertebral, non-vertebral, and hip fractures in women with osteoporosis (Cummings, et al). In this case, the patient tried a bisphosphonate and was intolerant of this according to the records provided. In addition, she has osteoporosis with a documented T-score of -2.6. All told, the services at issue were 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 services at issue were 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 63-year-old female enrollee has requested reimbursement for the Prolia injection performed on 11/21/14. The Health Insurer has denied this request indicating that the services at issue were investigational for treatment of the enrollees medical condition. The physician reviewer found according to the documentation submitted for review, the patient presents with osteoporosis with a history of fracture and failure of an FDA approved therapy for osteoporosis. There is a substantial amount of medical evidence that supports Prolia as an appropriate treatment option in patients with osteoporosis. Prolia is FDA approved for the treatment of osteoporosis. For the reasons provided, the Prolia injection performed on 11/21/14 was 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 services at issue were 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 Overturned

Summary Reviewer 


The parent of a 14-year-old male enrollee has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment center services provided from 7/12/16 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 behavioral health condition. The physician reviewer found the psychiatric residential treatment center services provided from 7/12/16 forward were and are medically necessary for treatment of the patients medical condition. In this case, the patient presents with impulsivity, poor decision making and anger outbursts which make him volatile and a potential danger to others. In addition, his behavior is of a nature that his family is unsafe around him. The documentation submitted for review demonstrates that multiple facetime family sessions did not go well. The patient was described as being agitated and frustrated and argumentative. On 8/19/16, the individual therapy note documents that he had been argumentative consistently throughout the day. He angrily teased a peer several times and aggressively argued with staff and peers. The patient lacks the coping skills needed for limit setting and disappointment. Given the above, residential treatment center services have been established as medically necessary for treatment of the patients behavioral health condition. Moreover, the treatment at issue is reasonably expected to improve the patients condition. Therefore, the services at issue were and are 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 63-year-old female enrollee has requested reimbursement for physical therapy services provided from 7/27/15 through 12/8/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees comminuted right patella fracture and shoulder pain.   The physician reviewer found that physical therapy services provided from 7/27/15 through 12/8/15 were not medically necessary for treatment of this patients medical condition. The documentation does not indicate that the patients deficits prevented her from independently forming an effective and appropriate home exercise program. The patient had extensive prior physical therapy and was educated in a home exercise program. There is no documentation of functional deficits that would improve significantly under supervised therapy beyond that expected with an independent home exercise program. The providers office notes indicate that on 6/1/15 and 6/30/15 her right shoulder range of motion and strength were unchanged and she had full right shoulder rotator cuff strength with some external rotation deficits. Her gait was much improved on 7/14/15 and her functional limitations were not of the complexity that they required continued supervised therapy. On 7/23/15 she was noted to be able to go upstairs without a handrail. Given these notes, the patients therapeutic benefit prior to 7/27/15 was met and any continued deficits did not require the supervision of the provider as her needs could have been met independently at home. Thus, the physical therapy services provided from 7/27/15 through 12/8/15 were not medically necessary. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 47-year-old female enrollee has requested reimbursement for PET scan performed on 8/19/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. This patient was diagnosed with anal squamous cell carcinoma, and chemoradiation was planned.  Studies have shown that PET/CT alters management in a meaningful number of patients, sufficient enough to justify its use as part of staging investigations in locally advanced cases. PET/CT is recommended for both staging and radiotherapy planning in anal cancer, and alters nodal status in enough cases to justify routine use in anal squamous cell carcinoma staging. Guidelines from the National Comprehensive Cancer Network recommend consideration of PET/CT in patients with anal cancer with a biopsy positive for squamous cell carcinoma. In this case, PET/CT was indicated to evaluate for distant (higher-stage) disease before undergoing chemoradiation, given the potential that the imaging would alter her staging or nodal status and therefore change her treatment planning and disease outcome. Therefore, the PET scan performed on 8/19/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 42-year-old female enrollee has requested reimbursement for a hysterectomy and hospital stay from 12/28/15 through 12/31/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who has had a history of chronic pelvic and abdominal pain.  The physician reviewer found that there is sufficient support for the medical necessity for the services at issue in this clinical setting. Chronic pelvic pain is a complex problem and it is poorly understood. It is typically very difficult to treat, as the disease process is multifactorial without one specific etiology, and clinically can present in different ways. Some common diagnoses include endometriosis, adhesions, irritable bowel syndrome, and interstitial cystitis. In this patients case, she had the appropriate workup to evaluate her chronic pelvic/abdominal pain to suggest that surgical management would be appropriate. An evaluation was performed between her primary care provider, gastroenterologist, general surgeon, urologist and gynecologist to determine the etiology of her symptoms. Moreover, the gynecologist indicated no signs and symptoms of depression as a contributing factor to her chronic pelvic pain that she would have required a psychologic evaluation. Given the multifactorial nature of the patients chronic pelvic pain, it was appropriate to have many specialties involved in the workup. She had a slightly enlarged retroverted and extremely tender uterus that was determined to be the cause of her pain. The decision at the time of laparoscopic evaluation was that the patient needed surgical management of her chronic pelvic pain. As such, medical management in this setting is  not likely to be successful. All told, the hysterectomy and hospital stay from 12/28/15 through 12/31/15 were medically necessary for treatment of this patients medical condition. Therefore, for the reasons stated above, the services at issue were 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

The parent of an eight-year-old male enrollee has requested authorization and coverage for Exondys 51. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees Duchenne muscular dystrophy. The physician reviewer found that there is sufficient support for the requested medication in this patients case. Antisense oligonucleotide therapies continue to improve, and the key issue of providing sufficient concentration of antisense oligonucleotides to affected muscle fibers remains at the forefront of drug development for Duchenne muscular dystrophy. From a clinical standpoint, this patient has maintained a remarkably stable neuromuscular examination since starting the therapy in 2015. Therefore, Exondys 51 is likely to be more effective than other treatment options. Based upon the information set forth above, the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

The parent of an eight-year-old male enrollee has requested authorization and coverage for Exondys 51. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees Duchenne muscular dystrophy. The physician reviewer found that there is sufficient support for the requested medication in this patients case. All other treatments for DMD are palliative, whereas Exondys 51 is disease-modifying. The patient has been on Exondys 51 on a clinical trial since 2015. His DMD disease trajectory is very different from that of his affected peers, who by the patients age, typically need to use a stroller for community excursions, developing muscle cramps and fatigue with exercise. In September 2016, the U.S. Food and Drug Administration (FDA) granted accelerated approval for eteplirsen (Exondys 51), a drug that acts to promote dystrophin production by restoring the translational reading frame of DMD through specific skipping of exon 51 in defective gene variants. Eteplirsen is applicable for approximately 14% of patients with DMD mutations. Most treatments currently available for DMD are palliative, aimed at prolonging the ability to walk, improving breathing and cardiac function. Treatment with corticosteroids has been found to be the most effective option for patients, resulting in improved muscle strength, prolongation of the ability to walk, and better pulmonary function. However, corticosteroids only delay disease progression, and treatment is associated with significant side effects, including weight gain, osteoporosis and cataracts. In this patients case, the requested medication is likely to be superior over other treatment options. In sum, Exondys 51 is likely to be more efficacious than other treatment modalities. Based upon the information set forth above, the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

The parent of an eight-year-old male enrollee has requested authorization and coverage for Exondys 51. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees Duchenne muscular dystrophy. The physician reviewer found that there is sufficient support for the requested medication in this patients case. The U.S. Food and Drug Administration (FDA) had approved this medication in this setting. Mendell and colleagues reported that eteplirsen restored dystrophin in the 30 and 50 mg/kg/week cohorts, and in subsequently treated, placebo-controlled subjects. No severe adverse events were encountered. This crossover study showed that those patients who received placebo and later received Exondys 51 also showed improvement, proving the medication is beneficial. Thus, Exondys 51 is likely to be more effective than other treatment alternatives. Based upon the information set forth above, the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 38-year-old male enrollee has requested reimbursement for physical therapy provided from 2/16/15 through 3/16/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees status post right knee arthroscopy and right hip arthroplasty. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the services at issue. According to the documentation submitted for review, the patient had already received extensive therapy prior to surgery with similar therapeutic content. His surgery was uncomplicated. Additionally, at least partial concurrent care would be expected after both surgeries. He had reached a plateau with the treatments already provided and an independent home exercise program could have met his needs without ongoing skilled physical therapy oversight. An independent exercise program could have been performed as often as needed rather than during scheduled therapy visits. All told, the physical therapy provided from 2/16/15 through 3/16/15 was not medically necessary in this clinical setting. For the reasons provided, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.