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

Summary Reviewer 3


A 61-year-old female enrollee has requested reimbursement for Collagen Type 1 C-telopeptide blood test that was performed on 11/21/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees post-menopausal osteoporosis.The physician reviewer found this patient has failed several therapies. Rather than watching her BMD decline further into the osteoporotic range, it was reasonable to utilize the Collagen Type 1 C-telopeptide to assess for adequate suppression of bone resorption in between Dexa scans. Consistent with the above-cited literature, the use of this test was likely to be more beneficial than any other available mechanisms of monitoring therapy in between the patients Dexa scans. Given the proven clinical utility of the Collagen Type 1 C-telopeptide in this setting, the use of the test was medically appropriate in this patients case. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 58-year-old male enrollee has requested authorization and coverage for epidural steroid injections. The Health Insurer has denied this request indicating that the requested services are not medically necessary for 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 physical examination and lumbar magnetic resonance imaging (MRI) do not show evidence of lumbar radiculopathy/radiculitis.  The peer-reviewed medical literature provides evidence for epidural steroid injections in documented cases of nerve root compression or radiculitis.  The patients chronic pain condition is not consistent with such a diagnosis.  There is a lack of support for the requested services in this clinical setting.  All told, the requested epidural steroid injections are not medically indicated for the treatment of this patient.  Therefore, the requested services 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


The parent of a 17-year-old male enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 6/30/14. 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 submitted documentation fails to demonstrate the superior efficacy of the services at issue.  There is a lack of controlled data to support measurement of infliximab levels after completing an induction dose of Remicade.  Theoretically, one could find the unique dose requirement for each patient and tailor therapy individually.  However, this approach has not been shown to lead to improved outcomes.  There is a lack of support for the services at issue in this clinical setting.  Therefore, Prometheus Anser IFX testing was not likely to have been of greater benefit than other methods of evaluation.  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


The parent of a 17-year-old male enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 6/30/14. 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 Prometheus Anser IFX test is a quantitative measurement of serum infliximab and anti-infliximab antibodies.  Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab 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 infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  However, while there have been testimonials, there are few well-controlled clinical trials to confirm that the testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  It has not yet been established whether the use of threshold levels aids in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  Therefore, Prometheus Anser IFX testing performed on 6/30/14 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


The parent of a 17-year-old male enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 6/30/14. 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 Anser IFX test was ordered to determine the drug concentration for Remicade at the end of induction.  This is not standard in the management of ulcerative colitis.  The use of Prometheus Anser IFX testing to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in 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.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing.  Per the current medical evidence, Prometheus Anser IFX testing performed on 6/30/14 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 42-year-old female enrollee has requested reimbursement for reduction mammaplasty performed on 12/03/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition.  The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  The patient had chronic pain of the neck, back, and shoulders, as well as the breasts.  Her examination was consistent with significant asymmetric macromastia.  Conservative management included nonsteroidal anti-inflammatory medications.  Her degree of resection was consistent with a significant breast reduction.  The patients symptoms had significantly impacted her activities of daily living.  Multiple medical evaluations provided confirmatory evidence of these findings.  The records document a functional problem that was directly related to her significant macromastia.  Breast reduction is a well-known procedure that directly addresses this functional deficit.  All told, reduction mammaplasty performed on 12/03/15 was medically indicated for the treatment of this patient.  Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A representative of a deceased female enrollee has requested reimbursement for inpatient admission in South Korea from 1/1/12 through 1/1/13. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who was diagnosed with leptomeningeal hemangioblastoma.The physician reviewer found that the submitted documentation supports the medical necessity for the services at issue in this clinical setting. There are detailed medical records that document the progression of this patients medical condition which support inpatient admission in South Korea. Moreover, the medical records prior to the hospital admission in South Korea confirm disease progression. The patient has had a longstanding diagnosis of hemangioblastoma and the records show that there was an acute worsening of the disease from May 2011 through June 2011. According to standard practice, the hospital admission rendered in South Korea was medically appropriate due to the acute urgent worsening and progression of her disease.  In a document dated 5/12/16, a treating provider from South Korea noted increased extent of leptomeningeal metastasis in the cerebellum, brainstem, and present in both cerebral hemisphere surface, and spinal cord surface. Thus, inpatient admission in South Korea from 1/1/12 through 1/1/13 was medically indicated in this case. Therefore, for the reasons state above, the services at issue were medically necessary for treatment of this patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 59-year-old male enrollee has requested reimbursement for right shoulder MRI performed on 8/27/19. 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 fails to demonstrate the medical necessity of the services at issue. In this clinical setting, an x-ray of the shoulder with appropriate views was likely to have been adequate to determine the treatment approach. There is a debate as to whether the MRI or ultrasound should be the next step. The ultrasound is felt to be more useful in the literature. Magnetic resonance arthrogram is the last step, if deemed necessary from the surgical viewpoint. In this case, there is no documentation of a thorough and detailed shoulder examination. X-rays have not been obtained. The MRI was requested when the patient became interested in a surgical solution to chronic pain. Chronic neck pain and extensive degenerative changes in the cervical spine have been mentioned which warrant a detailed cervical spine and neurological evaluation for radiculopathy. In the absence of documentation referencing the above, a request for MRI scan of the right shoulder is not supported by the literature. Therefore, the right shoulder MRI performed on 8/27/19 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 65-year-old male enrollee has requested authorization and coverage for Repatha SureClick 140 mg/mL auto-injector. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient has multiple risk factors for coronary artery disease and a strong family history of coronary artery disease. His 10-year risk of symptomatic cardiovascular disease is 15%, placing him in the intermediate risk category. In addition, he has known moderate coronary artery disease on cardiac catheterization, particularly calcified ostial disease of the right coronary artery. He requires aggressive risk factor modification and is making lifestyle changes. In addition, he has a history of intolerance to multiple statin medications. The patient has known established coronary artery disease and elevated 10-year risk of symptomatic disease, which could be brought down significantly with optimal risk factor management. The current evidence supports proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in this clinical setting. Therefore, Repatha SureClick 140 mg/mL auto-injector is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer

The patient is a 59-year-old male with diabetes, hypertension, and documented obstructive coronary disease, including myocardial infarction, coronary stent placement and coronary artery bypass surgery. The records noted hyperlipidemia, and the patient is intolerant of statin medications and ezetimibe. The patients low-density lipoprotein (LDL) cholesterol is reported at 151 mg/dl. The patient has requested authorization and coverage Repatha SureClick. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The Health Insurer noted that the preferred formulary alternative, Praluent, has not been tried or failed. Based on the records provided, the patient has documented obstructive coronary disease and hyperlipidemia with intolerance to multiple statins and ezetimibe but no documented trial of Praluent.  Praluent (alirocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria. In this setting, Praluent has shown to be safe and effective at significantly reducing cholesterol and has been associated with improved cardiac outcomes. There are a lack of trials that adequately compare or conclusively demonstrate an advantage with Repatha SureClick over Praluent. Based on the documentation provided, the preferred formulary alternative Praluent should be effective and sufficient in this circumstance. Thus, Repatha SureClick is not medically necessary for the treatment of this patient. Therefore, the requested medication is 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 51-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 4/15/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found by monitoring patients on infliximab with measurement of infliximab levels and antibodies to infliximab continues to be an area of intense investigation.  In general, infliximab levels correlate inversely with disease activity.  However, the target level of infliximab necessary to achieve clinical benefit remains unknown.  There is a lack of support for the services at issue in this clinical setting.  Many patients lose response to a tumor necrosis factor (TNF) alpha inhibitor for unclear reasons.  All told, Anser IFX testing performed on 4/15/14 was not likely to have been of greater benefit than other methods of evaluation.  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 51-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 4/15/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the Anser IFX Test is a quantitative measurement of serum infliximab and anti-infliximab antibodies.  Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab 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 infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  However, there is a lack of well-controlled clinical trials to confirm that use of the Anser IFX test leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  In addition, there are technical factors relating to the use of different assay methods across studies.  It has not yet been established whether the use of threshold levels aids in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  In sum, Anser IFX testing performed on 4/15/14 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 51-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 4/15/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found this patient had symptoms, primarily diarrhea, while on Remicade suggestive of loss of response.  Inadequate response or loss of response can occur for many reasons.  However, the appropriate method for determination of cause for symptoms while on therapy is not clear.  The use of Anser IFX to investigate inadequate response and direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management.  The effectiveness of Anser IFX in management of Crohns disease compared to conventional courses of action remains unproven in controlled clinical trials.  The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold levels been established.  Studies have found that anti-infliximab antibodies can be transient, with many patients who have these antibodies maintaining their response.  In sum, the superior efficacy of Anser IFX testing performed on 4/15/14 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 58-year-old female who has been diagnosed with multiple sclerosis and type 1 diabetes.  The patient has requested authorization and coverage for Acthar (corticotropin injectable gel 80 U/ml). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that standard therapy for acute exacerbations of multiple sclerosis has been high-dose corticosteroid therapy. Adrenocorticotropic hormone (ACTH, Acthar Gel) is also approved by the U.S. Food and Drug Administration (FDA) for the treatment of exacerbations of multiple sclerosis in adults.  Other therapies include plasmapharesis and intravenous immunoglobulin (IVIG). Plasmapharesis is generally reserved for treatment of relapses that are severe or refractory to treatment with high-dose corticosteroids or ACTH. IVIG is sometimes used in patients for whom high-dose corticosteroids are contraindicated or not tolerated, but there is a lack of consistent evidence for its use in relapse management. Ross and colleagues noted, aAdrenocorticotropic hormone gel, as previously noted, may be considered as an alternative treatment of multiple sclerosis relapses. In our experience, reasons for using adrenocorticotropic hormone include a lack of benefit established with corticosteroids, inability to tolerate corticosteroids or adverse effects, and poor intravenous access. Its efficacy has been studied in several published investigations, and treatment outcomes may be comparable to those seen with corticosteroids.a In a randomized, open-label, crossover study, Bell and colleagues evaluated 18 patients with multiple sclerosis treated with subcutaneous Acthar Gel and intravenous methylprednisolone. Preliminary results suggest that fewer drug-related adverse effects occurred with Acthar Gel than intravenous methylprednisolone for treatment of multiple sclerosis exacerbations. In this case, the patient has multiple sclerosis and is seeking approval for Acthar Gel for treatment of acute exacerbations. Acthar Gel is currently an FDA approved therapy for multiple sclerosis exacerbations, and the studies noted above report less adverse effects with Acthar Gel and comparable efficacy and treatment outcomes compared with intravenous corticosteroid therapy.  Clinically, Acthar Gel has been effective for the patient and she has not experienced any significant side effects with Acthar Gel. Therefore, Acthar (corticotropin injectable gel 80 U/ml) is medically necessary for the treatment of this patient.