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

Summary Reviewer 1

The patient is a 53-year-old female who had developed malignant melanoma on the skin of right medial thigh with a Breslows depth of approximately 0.4 mm. The DecisionDX-Melanoma gene assay performed on 9/15/17 revealed Class 1A molecular signature associated with a low risk of recurrence within five years. The patient has requested reimbursement for the genetic testing performed on 9/15/17, but the Health Insurer denied this request indicating that the services at issue were considered investigational for evaluation of the patients cutaneous melanoma.  There is a lack of peer reviewed published studies as to this tests superior efficacy when compared to other standard modalities. Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. DecisionDx-Melanoma assay assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as class 1, consistent with a low risk of metastasis, or class 2, suggestive of a high risk of metastasis. While the majority of clinical stage I patients will be disease free at five years, some stage I patients will develop advanced disease. According to the results of analysis of this patients melanoma performed with DecisionDx-Melanoma assay, the tumor was classified as class 1 with a low risk of near term within five years metastatic disease. In sum, while there is some support in the medical literature for the efficacy of the services at issue, genetic testing performed on 9/15/17 was not likely to have been of greater benefit than the available standard methods for the evaluation of patient.  Therefore, for the reasons stated above, the services at issue were not likely to have been 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 patient is a 53-year-old female who has been diagnosed with a melanoma on her thigh measuring 0.4 mm Breslow depth.  Her provider sent her tissue for molecular genetic testing to help determine the risk of spread of the tumor. The patient has requested reimbursement for the genetic testing performed on 9/15/17. The Health Insurer denied this request for reimbursement and noted that the services at issue were considered investigational for the evaluation of this patients medical condition.  The DecisionDx-Melanoma assay tests the tissue genetics of the melanoma and can stratify whether a melanoma is high risk for metastasis or not. The patients provider recommended her tissue be sent for a test called DecisionDX where the genes are examined for certain markers and then the lesion can be further stratified to tell if it is high risk for metastasis. This test has shown some accuracy determining risk of metastasis in thin thickness melanomas like this patients; however, decision-making based on the results of the test is indeterminate at this time. The treatment of this patient would not change based on the results of the examination. Moreover, this test is not considered a routine standard of care and is not currently recommended by the National Comprehensive Cancer Network (NCCN) guidelines. There is not enough published data to support its routine use.  Accordingly, the genetic testing performed on 9/15/17 was not likely to have been more effective than the available standard options for evaluating this patients medical condition.   Therefore, for the reasons stated above, the services at issue were not likely to have been 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 patient is a 53-year-old female with history of melanoma. The provider ordered genetic testing to assess the metastatic risk of the patients 0.4 mm Breslow depth melanoma affecting the right medial thigh.  The patient has requested reimbursement for the genetic testing performed on 9/15/17. The Health Insurer denied this request for reimbursement on the basis that the services at issue were considered investigational for the evaluation of this patients medical condition.  The use of this type of genetic testing is not considered a standard of care in this clinical setting. The National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting (Coit, et al). As such, the utilization of DecisionDx-Melanoma gene assay is not expected to affect the treatment or health outcome of this patients melanoma. In sum, the genetic testing performed on 9/15/17 was not likely to have been superior over the standard treatment options for the evaluation of this patients medical condition.  Therefore, for the reasons stated above, the services at issue were not likely to have been 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 35-year-old female enrollee has requested reimbursement for BRCA1, BRCA2 (breast cancer 1 and 2) (hereditary breast and ovarian cancer) gene analysis, full sequence analysis and common duplication/deletion variants in BRCA1 performed on 12/07/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the submitted documentation does not support the medical necessity of the services at issue. While the lifetime risk score completed by Myriad MyRisk was estimated to be 29.6%, higher than the 20% lifetime risk considered threshold for changes in management, this indicates that the patient should be considered for earlier or increased breast screening, not necessarily that genetic testing of BRCA1 and BRCA2 were indicated. Genetic testing for hereditary cancer predisposition syndromes are most useful in individuals who have a personal history of cancer or in those who have affected family members with known mutations. In this patients case, negative BRCA1 and BRCA2 testing did not reduce her risk, as the records do not document the cause of cancer in any of her family members, particularly in the paternal aunt, who is the only relative with cancer at a young age. The current medical evidence does not support the services at issue in this clinical setting. Therefore, BRCA1, BRCA2 (breast cancer 1 and 2) (hereditary breast and ovarian cancer) gene analysis, full sequence analysis and common duplication/deletion variants in BRCA1 performed on 12/07/18 were not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 58-year-old male enrollee has requested authorization and coverage for Testim. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees low testosterone.  The physician reviewer found that on the presented clinical records submitted for review, Testim is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patients testosterone levels are normal. There are no laboratory tests showing luteinizing hormone or follicle stimulation hormone levels. Furthermore, there is a lack of documentation demonstrating low bone mineral density, low libido or weight loss. Given the lack of support in the documentation provided, the request for Testim has not been established as medically necessary for treatment of the patients medical condition. Therefore, the requested medication is 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 a 16-year-old female enrollee has requested reimbursement for services at Provo Canyon School in Utah from 8/31/14 through 12/19/14. 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 submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. Outpatient treatment and least restrictive options are considered first lines of care as referenced by The American Academy of Child and Adolescent Psychiatry (Hales, et al). The standard of care for treatment of children and adolescents should be in the least restrictive setting as possible in order to maintain and foster natural supports (Winters, et al). It is further recommended that children should be treated in the setting that is least restrictive and disruptive to their lives. Inpatient or residential treatment is indicated only in emergencies or for children who have not responded to efforts at outpatient treatment. In a study by Barth and colleagues, children in intensive in-home therapy were more likely to live with family, make progress in school, not have trouble with the law, and have better placement permanence than youth who were treated in residential treatment facilities. In this patients case, she made significant progress regarding her behaviors and her ability to control her distress. By 8/1/14, her thoughts of self-harm decreased since her initial admission in May 2014.  The improvement in her symptoms indicated that she could have been managed in a less restrictive setting. While she had continued symptoms of anxiety and periods of emotionality, she was not displaying any significant or severe behavioral problems during the disputed period. She was noted to be cooperative in therapy and was insightful into her need for treatment and her behaviors.  The records indicate that the patient needed more treatment to further improve her social functioning, anxiety, family relationships, and self-harm thoughts. However, the submitted documentation indicates that this patient no longer needed the restrictiveness of a residential psychiatric treatment facility as she had stabilized enough over the previous three months of residential care to transition to a less restrictive setting by 8/31/14. The medical evidence support residential treatment when used for acute stabilization. However, there is a lack of evidenced based reviews to support residential treatment for long term care as in this patients case. All told, the services at Provo Canyon School in Utah from 8/31/14 through 12/19/14 were not medically necessary for 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 Overturned

Summary Reviewer 

The patient is a 40-year-old male with chronic left-sided low back pain. He has tried physical therapy as well as medications.  The patient has requested authorization and coverage for arthrodesis sacroiliac joint, percutaneous or minimally invasive. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient has localized pain to the sacroiliac joint. This pain has responded to anesthetic injection, indicating that the sacroiliac joint is the pain generator. The patient has failed reasonable nonsurgical treatments, and the current high-level evidence supports minimally invasive fusion to have superior outcomes to further conservative care. Therefore, arthrodesis sacroiliac joint, percutaneous or minimally invasive is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 30-year-old female enrollee has requested authorization and coverage for Adderall XR 90 mg daily. The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). The physician reviewer found there is a paucity of scientific literature supporting a dose of Adderall XR above 60 mg. Doses above 60 mg have not been demonstrated to be more effective than lower and safer doses of Adderall. There are also cardiovascular concerns with doses above 60 mg. There is no substantial evidence suggesting that 90 mg of Adderall XR is more efficacious than 60 mg. There is also concern for abuse potential with doses higher than recommended as tolerance, psychological dependence, and social disability can occur if taken at higher than recommended doses. Given these findings, the requested Adderall XR 90 mg daily is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication dosage is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 30-year-old female enrollee has requested authorization and coverage for Adderall XR 90 mg daily. The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). The physician reviewer found according to the U.S. Food and Drug Administration (FDA) approval for Adderall XR, there is no proven benefit with doses above 60 mg in adults with ADHD. The provider notes that the patient has been stable on a dose of Adderall XR 90 mg daily for seven years. High dose stimulants can be risky for substance induced psychosis, mania, anxiety and can also contribute or worsen cardiac conditions. All told, the requested Adderall XR 90 mg daily is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication dosage is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 30-year-old female enrollee has requested authorization and coverage for Adderall XR 90 mg daily. The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). The physician reviewer found the provider reports that the patient has been stable for the extensive period of time of seven years on a regimen of Adderall XR 60 mg in the morning and 30 mg in the afternoon. The patient is noted to have no side effects and is sleeping well. This supports the efficacy of the requested medication at a daily dose of 90 mg. Therefore, the requested brand Adderall XR 90 mg daily 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, the requested medication dosage 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 70-year-old female enrollee has requested reimbursement for an intermittent limb compression device provided from 10/13/16 through 10/28/16. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees right knee pain. The physician reviewer found that the patient underwent arthroscopic surgery for osteoarthritis of the right knee including degenerative meniscal tears and chondromalacia on 10/13/16. There is no prior history of thromboembolism. The recent medical literature suggests that the incidence of symptomatic venous thromboembolism after arthroscopic knee surgery is very low and therefore the guidelines do not recommend intermittent pneumatic compression or pharmacotherapy postoperatively (Mauck, et al). The guidelines from the American College of Chest Physicians and American Academy of Orthopedic Surgeons agree that routine prophylaxis to prevent symptomatic venous thromboembolism is not needed for patients undergoing outpatient knee arthroscopy (Falck-Ytter, et al). For these reasons, the intermittent pneumatic compression provided from 10/13/16 through 10/28/16 was not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the device at issue was 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 63-year-old male enrollee has requested authorization and coverage for stereotactic body radiotherapy (SBRT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees liver cancer. The physician reviewer found the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The most recent National Comprehensive Cancer Network (NCCN) guidelines for colon cancer state that In patients with a limited number of liver or lung metastases, radiotherapy can be considered in highly selected cases. For small liver lesions, it is well-established that SBRT yields high rates of control. In addition, radiation techniques other than SBRT will not likely allow adequate dose escalation to sufficiently treat the tumor or provide adequate normal tissue sparing. For this patient, with a lesion near the hilum radiofrequency ablation (RFA) is not an option as the tumor cannot be sufficiently heated as the vascular flow dissipates the heat, and there is a risk of vascular trauma such that RFA is contraindicated and conventional radiation is likely to be less efficacious. Therefore, SBRT 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, 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 63-year-old male enrollee has requested authorization and coverage for stereotactic body radiotherapy (SBRT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees liver cancer. The physician reviewer found SBRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with a long history of oligometastatic disease from a diagnosis of colon cancer. The peer-reviewed literature demonstrates that aggressive local therapy in the form of stereotactic body radiation can be beneficial for patients with oligometastatic disease (Palma, et al; Hanna and Landau). In addition, the National Comprehensive Cancer Network (NCCN) guidelines state that SBRT can be utilized in the management of liver metastases from colon cancer. Therefore, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are 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 male enrollee has requested authorization and coverage for stereotactic body radiotherapy (SBRT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees liver cancer. The physician reviewer found SBRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with a single metastatic lesion in liver. SBRT has been used to treat primary liver cancer as well as metastatic lesions in liver. There are several clinical published studies to support SBRT for such clinical conditions (Lee, et al).  Moreover, the provider documents that the patient is not a candidate for radiofrequency ablation as the lesion is close to vessels. For the reasons provided, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are 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 Upheld

Summary Reviewer 1


A 37-year-old female enrollee has requested authorization and coverage for bronchoscopic thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is investigational for treatment of the enrollees persistent asthma. The physician reviewer found that based on the documentation provided, there is inadequate evidence for a diagnosis of asthma in this patient. There was no documentation provided to describe the onset of the patients symptoms and pulmonary function testing is normal and does not show evidence of obstruction or bronchodilator response. It would be expected that a patient with severe persistent asthma would demonstrate some abnormality on pulmonary function testing. There is also inadequate data on the patients history of exacerbations which is a prime consideration for bronchoscopic thermoplasty. Consideration should be given to alternate diagnoses such as inducible laryngeal obstruction, excessive dynamic airway collapse and reactive airways dysfunction syndrome for this patients symptoms. In the absence of documented asthma based on physical exam findings, clinical symptoms, exacerbation history, and objective lung function testing, the requested bronchoscopic thermoplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be upheld.