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

Summary Reviewer 1


A 38-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 11/11/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis.  The physician reviewer found that the Prometheus Anser IFX test is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies. Some evidence exists that low serum levels of IFX and/or the presence of antibodies to IFX may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear. Some evidence exists that low serum levels of IFX or the presence of IFX antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al). All told, 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. Accordingly, the Anser IFX testing performed on 11/11/15 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 38-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 11/11/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis.  The physician reviewer found that the Anser IFX test was ordered to determine the cause for the patients possible loss of response to Remicade. However, management of ulcerative colitis using the Anser IFX has not been standardized, and recommendations for management based on test results have not been formed (Kornbluth and Sachar). In addition, the use of Anser IFX to direct treatment has not been clinically proven to improve patient outcomes or alter patient management in high-quality controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold drug levels been established (Steenholdt, et al). Studies have found that anti-infliximab antibodies can be transient, with many patients who have these antibodies maintaining their response (Vande Casteele, et al; Nanda, et al). A recent study concluded that prospective evaluation of the value of measuring serum concentrations of infliximab should be performed before these data can be included in patient management strategies (Adedokun, et al). One study, with some patients undergoing dose intensification following initial non-response, showed no difference in serum levels of infliximab between patients who responded to dose intensification versus those who did not (Pariente, et al). Based on the clinical literature, the Anser IFX testing performed on 11/11/15 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 38-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 11/11/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis.  The physician reviewer found that the use biologics such as Remicade in ulcerative colitis has been proven. However, when a patient loses response to Remicade, this may entail increasing the dose. In this case, there is concern as the disease is active and the patient is symptomatic. The concern between total loss of response, low antibody level to the biologic, or a completely different diagnosis entails completely different measures varying from change or increase in dose of biologic to alternate treatment. Moreover, it has been shown in the medical literature that checking for such antibodies helps optimize clinical response by helping achieve a more optimal drug concentration. Given this support, the Anser IFX testing performed on 11/11/15 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 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 52-year-old female enrollee has requested reimbursement for bilateral reduction mastopexies provided on 3/21/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees bilateral macromastia with ptosis. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The records do not document that the patient had typical signs and symptoms associated with functional impairment related to macromastia. There was no medical description of pain, shoulder grooving, chronic rashes or other signs and symptoms to support that the planned procedure was reconstructive surgery. Thus, bilateral reduction mastopexies provided on 3/21/17 was not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 64-year-old female enrollee has requested reimbursement for residential mental health services provided from 4/6/15 through 5/5/15. The Health Insurer 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 that the residential mental health services provided from 4/6/15 through 5/5/15 were not medically necessary for treatment of the patients medical condition. The documentation submitted for review does not support the initial residential placement. The patient felt isolated and limited in her pursuit of quality of life activities in caring for her husband. However, she did have a supportive brother and was motivated for treatment. Although formidable in its persistence and intensity, there was no mention of a change in the symptom complex. The patient was seeing a psychiatrist in the community, but the extent of non-pharmacologic interventions, including respite care, was not reported. Further, the patient was not seeing a psychologist or therapist at the time of admission. Finally, the patient had not failed a less restrictive treatment setting, such as partial hospitalization or an intensive outpatient program, during this episode of illness. This is significant in this case for two reasons: first, current psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment; second, there was no evidence to suggest that a less restrictive treatment setting would have been insufficient. Thus, the residential mental health services at issue were not medically necessary for treatment of the patients behavioral health 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The parent of an 11-year-old male enrollee has requested authorization and coverage for orthoptic and pleoptic training. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The patients optometric record carries no diagnosis of ocular pathology, only the functional diagnosis of convergence excess. There is no documentation provided of any illness, injury, or significant organic malfunctioning of the patients eyes. The providers letter indicates that the patient has several psychological disorders. There is insufficient evidence supporting the medical efficacy of the requested orthoptic and/or pleoptic training. Per the American Academy of Ophthalmology, there is a lack of evidence-based information supporting the effectiveness of vision therapy. Vision therapy is not within the standard of medical care for children with reading difficulties, attention problems, or other psychological disorders. Therefore, the requested orthoptic and/or pleoptic training is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 57-year-old male enrollee has requested gene testing performed on 9/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees uveal melanoma.  The physician reviewer found that the testing performed in this case is a study of 15 to 31 genes in an individuals melanoma cells. It has been used to classify that melanoma as having either a high or low risk of metastasis. Per the medical evidence, this testing is particularly useful in the analysis and clinical follow-up of uveal melanoma. This has been validated in several studies and has become a standard test in this setting. Its clinical value lies in determining the need for intense surveillance and possibly to assist in the decision as to adjuvant therapy. Thus, gene testing performed on 9/11/17 was 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 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 57-year-old male enrollee has requested gene testing performed on 9/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees uveal melanoma.  The physician reviewer found that local treatment for primary uveal melanoma is effective in preventing local recurrence in over 95 percent of cases, yet up to 50 percent of patients are at risk for metastatic disease. The high risk of metastatic disease is thought to be due to a propensity for early micrometastasis followed by a variable latency period prior to the emergence of overt metastatic disease. Gene expression profiling (GEP) has been shown to be superior to chromosomal markers, as well as clinical and histopathological prognostic factors, for defining groups at high risk for the development of metastatic disease. Using primary uveal melanoma samples obtained by fine needle biopsy, GEP classifies tumors as having low (class 1) or high (class 2) metastatic potential depending on the expression of 12 discriminating genes and three control genes. This profile test is considered a standard of care. In sum, gene testing performed on 9/11/17 was 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 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 57-year-old male enrollee has requested gene testing performed on 9/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees uveal melanoma.  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The only clinical information available for review are the requisition and report of test results. Per the medical evidence, management includes surveillance testing. However, there was insufficient information submitted to determine if there were other features of the patients clinical situation that would make him moderate or high risk.  Therefore, there is insufficient information to determine whether the services at issue were likely to be more beneficial than any available standard therapy.  Thus, gene testing performed on 9/11/17 was not likely to have been more effective 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 


A 50-year-old female enrollee has requested authorization and coverage for stretching devices (E1830 and E1399). The Health Insurer has denied this request indicating that the requested devices are not medically necessary for treatment of the enrollees medical condition status post hammertoe correction. The physician reviewer found that the requested Dynasplint toe flexion system stretching devices are not medically necessary for treatment of the patients condition. There is a lack of sufficient evidence in the published medical literature to permit conclusions on the safety, efficacy and long-term outcomes of the proposed stretching devices. In this case, the use of static progressive stretch splint devices alone or combined with standard physical therapy is not medically necessary. In addition, there is a lack of documentation demonstrating that the patient is unable to benefit from standard physical therapy modalities because of an inability to exercise or the patient has participated in a treatment plan with documentation of no improvement for four months. Moreover, the use of patient-actuated serial stretch and bi-directional static progressive devices is not the standard of care in this clinical setting. All told, the request for stretching devices (E1830 and E1399) has not been established as medically necessary for the patients medical condition.  Therefore, the requested devices are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 59-year-old female enrollee has requested reimbursement for Decision DX melanoma assay performed on 5/19/16.  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 the prognosis of cutaneous melanoma has classically been determined by the applying the staging system spelled out by Balch.  Mitotic index has also been thought to add to these statistics.  By Balch tables, this patients melanoma would be classified as a T1a melanoma, or stage 1A.  Such a tumor would have a predicted ten year survival of at least 88%.  Decision DX melanoma assay is a study of 31 genes in melanoma cells.  It then classifies that particular melanoma as either Class 1 (with a 97% disease free rate at five years) or Class 2 (with a 20-30% disease free rate at five years).  Gerami reported on 217 cases, with good correlation between prognosis and Decision DX classification, in patients undergoing sentinel node sampling.  However, it is not clear as yet how Decision DX data compares to the ten-year data of Balch determinations, and whether it can be used additionally to make clinical decisions.  This is especially in question in this particular patient, given her pathologic findings and excellent prognosis.  Thus, Decision DX melanoma assay performed on 5/19/16 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 2

A 59-year-old female enrollee has requested reimbursement for Decision DX melanoma assay performed on 5/19/16.  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, 0.76-1.0 mm.  Metastases to regional lymph nodes may be amenable to excision, but they suggest 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 the Decision DX melanoma assay 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.  The test is very novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques.  Therefore, Decision DX melanoma assay performed on 5/19/16 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 59-year-old female enrollee has requested reimbursement for Decision DX melanoma assay performed on 5/19/16.  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 the decision DX melanoma assay has been developed in patients with stage I and II cutaneous melanoma.  However, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials according to published data available. It does not aid in the decision for re-excision. In sum, Decision DX melanoma assay performed on 5/19/16 was not likely to be of greater benefit than 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

An 18-year-old male enrollee has requested reimbursement for residential mental health treatment for children and adolescents provided from 11/16/17 through 1/04/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2. The medical records indicate that the patient was not actively suicidal at any time, although he had recent passive suicidal ideation without intent to harm himself. With regards to functional status, the records support a score of 2. The patient has had some issues with level of function that were sporadic nature. He showed intact activities of daily living. In terms of comorbidity, the records support a score of 1. The patient does not have active medical problems or substance use. With regards to level of stress of the recovery environment, the records support a score of 2. There was no indication of an unsafe home environment. In terms of level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 3. It appears that the patient has had minimal prior treatment and was cooperative in the residential treatment center program at issue. In terms of acceptance and engagement, the records support a score of 2. The patient actively participated in therapy on admission. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient had a composite score of 16.  This score correlates with intensive outpatient services. Therefore, residential mental health treatment for children and adolescents provided from 11/16/17 through 1/04/18 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 47-year-old male enrollee has requested authorization and coverage for Harvoni.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C.  The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks.  The current medical evidence supports the requested medication in this clinical setting.  All told, Harvoni is medically indicated 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.