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

Summary Reviewer 3
A 19-year-old female enrollee has requested reimbursement for electromyography (EMG) and electroencephalogram (EEG) monitoring during spine surgery performed on 12/05/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that in spinal deformity corrective operations, the use of intraoperative neurophysiologic monitoring has become standard of the care. The medical literature has shown the beneficial effects of this type of intraoperative monitoring. This type of monitoring has been helpful in avoiding potential catastrophic neurologic injury and allows the surgeons to be vigilant and to be able to reverse neurophysiological changes. This modality may prevent catastrophic permanent neurologic injury. Therefore, EMG and EEG monitoring during spine surgery performed on 12/05/19 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

An 81-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 2/27/18. 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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic count may add to these statistics. DecisionDx-Melanoma testing is a 31-gene assay of an individuals melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami and colleagues reported on 217 cases with good correlation between prognosis and DecisionDx-Melanoma class, in patients undergoing sentinel node sampling. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear if the assay can be used to make clinical decisions. Therefore, DecisionDx-Melanoma testing performed on 2/27/18 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

An 81-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 2/27/18. 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 the current medical evidence does not support the services at issue in this clinical setting. 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 2/27/18 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 3

An 81-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 2/27/18. 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, 0.76-1.0 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 2/27/18 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The patient is a 63-year-old male with a history of urothelial cancer status post resection. The patient developed gross hematuria and computed tomography (CT) abdomen in August 2015 revealed left hydroureter and mild left hydronephrosis with soft tissue attenuation seen in distal left ureter. The patient underwent FoundationOne testing on 5/4/16. The patient is requesting reimbursement for the FoundationOne gene testing performed on 5/4/16. The Health Insurer has denied this request as investigational. The FoundationOne gene testing performed on 5/4/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The National Comprehensive Cancer Network (NCCN) guidelines do not include next generation sequencing in the treatment of urothelial cancer. Clinical outcomes in the treatment of metastatic bladder cancer is not based on complete genomic panel testing. Broad genomic panel testing such as FoundationOne is not considered the standard of care in tis clinical setting. The available literature on clinical utility consists of a small number of uncontrolled studies, and nonrandomized controlled trials that use imperfect comparators. This evidence is not sufficient to make any conclusions on clinical utility. In addition, there is potential for harm if ineffective therapy is given based on test results, because there may be adverse effects of therapy in absence of a benefit. All told, 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 Overturned

Summary Reviewer 2

The patient is a 63-year-old male with a history of metastatic urothelial cancer. The patient has been treated with surgery and cisplatin and gemcitabine and most recently on clinical trial with immunotherapy. The patient is requesting reimbursement for the FoundationOne gene testing performed on 5/4/16. The Health Insurer has denied this request as investigational. In this case, the patient has already progressed after first-line therapy. Molecular analysis of urothelial cancers has shown that 60% have alterations that can be targeted by drugs already approved for use in other indications or in clinical trials. Single patient benefit has been reported. Clinical trials are recommended by National Comprehensive Cancer Network (NCCN) guidelines. Testing with FoundationOne can help identify available clinical trials or drugs approved for other indications that may be available for compassionate use. For the reasons provided, FoundationOne gene testing performed on 5/4/16 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 testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

The patient is a 63-year-old male with a history of urothelial cancer. He presented with gross hematuria when a large 17 cm soft tissue mass was found in the distal left ureter. He started with neoadjuvant chemotherapy with gemcitabine and cisplatin for four cycles with some response. A cystoscopy showed a T1 transitional cell carcinoma of the bladder. He underwent a transurethral resection. A left abdominal lymph node was sampled and was positive for metastatic disease. A sample of his tumor was sent to Foundation Medicine for FoundationOne mutational analysis. The patient is requesting reimbursement for the FoundationOne gene testing (CPT codes 81201, 81235 and 81321) performed on 5/4/16. The Health Insurer has denied this request as investigational. Metastatic bladder cancer has a poor prognosis. One standard regimen for advanced bladder cancer is methotrexate, vincristine, doxorubicin, and cisplatin (MVAC). This regimen is toxic with many patients requiring hospitalization due to myelosuppression or mucositis. Therefore, not all patients are suitable. One regimen that stands out is that of gemcitabine/cisplatin which was equivalent to MVAC in one clinical trial. Some complete responses were seen with this regimen (von der Maase, et al). According to the National Cancer Institutes Physicians Data Query, gemcitabine/cisplatin is a reasonable alternative for those patients that may not tolerate MVAC. In this case, the patient was tried on MVAC and his tumor showed a poor response. A study by Von Hoff and colleagues of 86 patients where the progression-free survival on regimen selected by molecular profiling was compared to progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has very significant results for patients with stage IV tumors. As such, the results from molecular profiling offer a rational selection of the next regimen. Therefore, the FoundationOne gene testing (CPT codes 81201, 81235 and 81321) performed on 5/4/16 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 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 56-year-old male enrollee has requested reimbursement and prospective authorization and coverage for radiation therapy for bone metastases.  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 metastatic prostate cancer.   The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting.  Based on the information submitted, the provider has not given a sufficient reason for the use of three-dimensional conformal technique in the treatment of this bone metastasis.  Currently, there is a lack of clinical data in the medical literature to suggest that treatment with three-dimensional conformal technique offers a clinical benefit compared to conventional radiation therapy techniques in the palliative setting for uncomplicated bone metastases.  Additionally, for uncomplicated bone metastases, the use of stereotactic body radiation therapy is not medically necessary. There is a lack of clinical guidelines that endorse the use of stereotactic body radiation therapy in the initial treatment of prostate cancer metastases.  All told, radiation therapy for bone metastases was not and is not medically indicated for the treatment of this patient.  Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 36-year-old female enrollee has requested authorization and coverage for peripheral nerve stimulator (implant of neuroelectrodes (G4555)). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees paraclavicular and neck pain.  The physician reviewer found that this right handed patient has chronic refractory neuropathic pain of her right neck and right shoulder. She has failed use of a SCS as treatment for her pain as well as other standard treatment modalities. According to the American Academy of Neurology (AAN) guidelines, SCS is used to treat neuropathic pain, and is considered to be a surgery of last resort when all other treatment options have failed. She has been offered a peripheral nerve stimulator trial. Peripheral nerve stimulation has been shown to be safe and effective (Petersen and Slavin). Since she has failed use of the SCS, the peripheral nerve stimulator is the only available modality to treat her current pain (Al-Jehani and Jacques). Thus, the requested peripheral nerve stimulator (implant of neuroelectrodes (G4555)) is likely to be more beneficial for this patient than any available standard treatment. Based upon the information set forth above, I have determined the requested services are 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 36-year-old female enrollee has requested authorization and coverage for peripheral nerve stimulator (implant of neuroelectrodes (G4555)). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees paraclavicular and neck pain.  The physician reviewer found that although peripheral nerve stimulation is a novel treatment, several prospective studies have demonstrated its efficacy in this clinical setting. In the medical literature, Deogaonkar and Slavin found that peripheral nerve stimulation works well in both established indications, such as post-traumatic and postsurgical neuropathy. Given the lack of other treatment modalities available to this patient, she is likely to benefit from a trial of peripheral nerve stimulation to proceed for the treatment of her neuropathic pain. Consistent with these findings, the requested peripheral nerve stimulator (implant of neuroelectrodes (G4555)) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the requested services are 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 36-year-old female enrollee has requested authorization and coverage for peripheral nerve stimulator (implant of neuroelectrodes (G4555)). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees paraclavicular and neck pain.  The physician reviewer found that currently, there is a paucity of clinical data on peripheral nerve stimulation. Further, there is a lack of an indication for the peripheral nerve stimulation requested in this patients case. Considering the previous poor response to surgical interventions, which included thoracic outlet syndrome decompression as well as spinal cord stimulation, the recommended peripheral nerve stimulation does not appear to be superior to other modalities of treatments available. All told, the requested peripheral nerve stimulator (implant of neuroelectrodes (G4555)) is not likely to provide this patient with an improved health outcome beyond that anticipated with standard available alternatives. Based upon the information set forth above, I have determined 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 Overturned

Summary Reviewer 1


A 54-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 12/18/15.  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 current medical evidence supports the services at issue in this patients case.  According to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Thus, the medical literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate. In sum, digital breast tomosynthesis performed on 12/18/15 was likely to have been superior over other modalities.  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 54-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 12/18/15.  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 current medical evidence supports the services at issue in this patients case.  The addition of digital breast tomosynthesis to screening mammography reduces false positives and increases cancer detection when compared to two-dimensional mammography alone.  Breast tomosynthesis allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue (asymmetries).  The medical literature supports the use of breast tomosynthesis in the routine screening population.  Therefore, digital breast tomosynthesis performed on 12/18/15 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 54-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 12/18/15.  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 breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this case, the patients breasts were not particularly dense.  However, the records noted a cyst which had increased in size from the 1.5 cm that was previously noted in 2009, to a size approaching 5 cm.  The significant increase in size is concerning, and on occasion, breast tomosynthesis will provide significant information in terms of the contour or margination of a mass.  The increase in size is a reasonable indication for breast tomosynthesis.  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 38-year-old female enrollee has requested authorization and coverage for rituximab infusions at UCSF Medical Center. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees rheumatoid arthritis. The physician reviewer found there are multiple studies demonstrating safety for long-term use of rituximab in this clinical setting. However, the risk of infusion reactions occur within 30-120 minutes of infusion and occur in 30-45% of patients. To prevent reactions, there are pretreatment medications which are recommended. Reactions may require aggressive treatments to include treatment of anaphylactic symptoms. It is therefore recommended that the patient continues to receive the rituximab infusions at the UCSF Medical Center. Therefore, the requested rituximab infusions at UCSF Medical Center are supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested services 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 59-year-old female enrollee has requested reimbursement for the OncotypeDX assay provided on 3/31/16. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees high grade ductal carcinoma in situ (DCIS).The physician reviewer found that a lumpectomy for DCIS, the standard of care is radiation therapy to the remaining breast (Goodwin, et al). However, there is controversy as to whether every patient should receive radiation, or whether it can be individualized. Many efforts have been made to determine just who should receive radiation and who does not need it (Silverstein and Lagois). However, it does not give real information about the impact of radiation therapy on those with a high risk, such that it has not become standard of practice. Furthermore, this patient had several features that would have meant a recommendation for radiation therapy, even without the assay results. Thus, the OncotypeDX assay provided on 3/31/16 was not medically necessary for evaluation of the patients medical condition. Based on the foregoing discussion, the testing at issue was not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.