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

Summary Reviewer 3


A 55-year-old male enrollee has requested reimbursement for the prostate cancer antigen 3 (PCA3) gene testing performed on 1/30/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the PCA3 testing was likely to be more effective for this patient than other available treatment options. PCA3 is expressed by most prostate cancers and has been analyzed as a screening test in clinical trials with sensitivities and specificities. PCA3 is appropriately used to recommend biopsy in those patients with indeterminate PSA levels or in those with initial negative prostate biopsies (Marks, et al; Deras, et al). In this case, the test was appropriately used to decide upon biopsy and the medical evidence supports it use in this clinical setting. In sum, the PCA3 testing 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 59-year-old female enrollee has requested authorization and coverage for Toujeo SoloStar 300 units/mL. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees type 2 diabetes with hyperglycemia. The physician reviewer found this patient is not intolerant of Lantus and has not been treated with Levemir, as recommended by the Health Insurer. While the control was reportedly better on the Toujeo SoloStar, the records do not adequately specify what else has changed with the insulin and the patients treatment plan. Further, the documentation does not indicate the patient was having low A1c levels. Overall, the relevant medical studies indicate that Toujeo SoloStar is as good in terms of A1c control as Lantus, but not superior to Lantus. All told, the records do not support the medical necessity of the requested Toujeo SoloStar 300 units/mL for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 22-year-old male enrollee has requested authorization and coverage for transcranial magnetic stimulation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. Based on the patients PHQ-9 depression score, it appears that he has serious depression. Current literature does not indicate that transcranial magnetic stimulation needs to follow numerous medication failures. This patient does not appear to have any comorbid substance abuse or personality disorders. The evidence base for transcranial magnetic stimulation has grown over the past several years, and this treatment has thereby gained U.S. Food and Drug Administration (FDA) approval for the treatment of depression. The evidence available on the use of repetitive transcranial magnetic stimulation for adults indicates that this treatment is approximately twice as effective as a sham procedure. There is supporting evidence in the literature that numerous medication trials do not often yield higher levels of success. This patient has reportedly failed several separate medication trials in the past. Based upon the patients level of depression and lack of response to antidepressant treatment and psychotherapy, the requested services are medically indicated. Therefore, transcranial magnetic stimulation is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 63-year-old female enrollee has requested authorization and coverage for Harvoni for 12 weeks or Harvoni for eight weeks in the alternative. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 1a. The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for treatment of this patients hepatitis C virus infection. In conclusion, the requested medication is 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 

The parent of an eight-year-old male enrollee has requested authorization and coverage for Omnitrope (somatropin) 100 mg cartridge, 0.8 mg per day. 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 the submitted documentation supports the requested medication in this clinical setting. This patient does not have a known hypothalamic-pituitary defect or a known deficiency of at least one pituitary hormone (other than growth hormone), which would allow the diagnosis of growth hormone deficiency without growth hormone stimulation testing.  In addition, this patient does not have a medical condition for which growth hormone is strongly recommended, such as chronic renal insufficiency, IGF-1 deficiency or Prader-Willi syndrome. Although increasing numbers of patients with Noonan syndrome are receiving growth hormone therapy, this patient does not meet the diagnostic criteria for Noonan syndrome and has not seen a geneticist to confirm the diagnosis.  Based on this patients normal laboratory results and delayed bone age, the most likely diagnoses are idiopathic short stature, constitutional delay and familial short stature (or a combination of these). The 2008 consensus guidelines on idiopathic short stature are most relevant and includes no clear biochemical criteria for initiating growth hormone therapy and no requirement for growth hormone stimulation testing. This patients consistently low height standard deviation and predicted final adult height support the use of recombinant growth hormone therapy in this case. Therefore, Omnitrope (somatropin) 100 mg cartridge, 0.8 mg per day is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 43-year-old female enrollee has requested reimbursement for the blood testing provided on 1/17/17. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cardiovascular risk. The physician reviewer found that the records indicate that this patient has no history of cardiovascular disease nor any significant risk factors for cardiovascular disease other than an elevated body mass index (BMI). There is no history of hypertension, diabetes, cigarette smoking, or family history of early cardiovascular disease. She has a negative risk factor in that her HDL cholesterol is above 60 and her LDL cholesterol is only mildly above the optimal range. The patients 10-year cardiovascular risk is very low (0.4%) based on the American Heart Association (AHA) and American College of Cardiology (Goff, et al; Stone, et al). In this clinical instance, given the low 10-year cardiovascular risk using traditional clinical and laboratory criteria, with no clinical cardiovascular risk factors, additional advanced risk factor testing to assess lipid particle number and size is not indicated in this clinical situation and would not change treatment recommendations (Mora, et al). Given these findings, the blood testing provided on 1/17/17 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 43-year-old female enrollee has requested reimbursement for the blood testing provided on 1/17/17. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cardiovascular risk. The physician reviewer found that the use of the advanced lipoprotein testing with measurement of low density lipoprotein (LDL) cholesterol particle numbers remains controversial. While some providers have advocated for its use, the American College of Cardiology (ACC) guidelines do not support its use, recommending instead standard risk assessment protocols and standard lipid profile testing (Stone, et al). The ACC moved away from specific target goals of LDL in their most recent guidelines, based on review of outcome studies. Lloyd-Jones and colleagues provided an expert consensus update from the ACC and it does not mention the use of advanced lipid testing. Overall, the guidelines do not establish a strong recommendation for use of the advanced lipid profiles at this time. Thus, the blood testing provided on 1/17/17 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 43-year-old female enrollee has requested reimbursement for the blood testing provided on 1/17/17. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cardiovascular risk. The physician reviewer found that based on the records provided, this patient has no documented increased coronary risk. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of LDL cholesterol, LDL particle number, high density lipoprotein (HDL) cholesterol subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine (Greenland, et al; Stone, et al). Treatment changes or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis (Lonn; Toole, et al). Moreover, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. All told, the blood testing provided on 1/17/17 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 1

A 35-year-old male enrollee has requested authorization and coverage for Actemra 400 mg/ 20 ml vial. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees anti-neutrophil cytoplasmic autoantibodies (ANCA) associated crescentic and immune complex glomerulonephritis. The physician reviewer found in this clinical setting, the patients disease is advanced, thereby lowering likelihood of a significant response to treatment with the requested medication. In addition, Actemra is not U.S. Food and Drug Administration (FDA) approved for this patients diagnosis. Also, the documentation infers that the patients underlying chronic kidney disease may not be the sole cause of his progressive renal condition. Given the lack of FDA indication, combined with the low likelihood of benefit with his advanced disease, Actemra 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 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 35-year-old male enrollee has requested authorization and coverage for Actemra 400 mg/ 20 ml vial. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees anti-neutrophil cytoplasmic autoantibodies (ANCA) associated crescentic and immune complex glomerulonephritis. The physician reviewer found according to the Clinical Practice Guidelines for Glomerulonephritis, crescentic glomerulonephritis with ANCA is usually treated with a set of three pulsed doses of methylprednisolone, prednisone 60 gm/day followed by a taper; and cyclophosphamide for six months followed by azathioprine for 18 months. Plasmapheresis is added if there is alveolar hemorrhage and/or dialysis requirement. Recurrences are treated with rituximab. Rituximab may also be a substitute for cyclophosphamide for initial therapy. Recurrences are retreated with the same agents. However, there is a lack of medical literature supporting tocilizumab for the treatment of ANCA. All told, the request for Actemra is not likely to be more beneficial for treatment of the patients medical condition than other modalities. Based upon the information set forth above, the requested medication 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 35-year-old male enrollee has requested authorization and coverage for Actemra 400 mg/ 20 ml vial. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees anti-neutrophil cytoplasmic autoantibodies (ANCA) associated crescentic and immune complex glomerulonephritis. The physician reviewer found according to the documentation submitted for review, the patient has tried all conventional treatments for his ANCA associated crescentic and immune complex glomerulonephritis condition. His renal function has deteriorated with his creatinine on 3/15/15 at 4.0 with potassium of 5.2. Given his present condition and his previous response to medical therapies, at this time Actemra 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 is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 66-year-old female enrollee has requested reimbursement for laboratory testing (CPT code 84999) provided on 9/4/17. 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 ADA test is a quantitative measurement of serum adalimumab (ADA) and anti-ADA antibodies. Some evidence exists that low serum levels of adalimumab and/or the presence of antibodies to adalimumab 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. However, in a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. Moreover, the reasons for therapeutic failures remain unclear. Overall, 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). Accordingly, the laboratory testing (CPT code 84999) provided on 9/4/17 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 66-year-old female enrollee has requested reimbursement for laboratory testing (CPT code 84999) provided on 9/4/17. 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 there is currently insufficient medical evidence to support the effectiveness of Anser ADA compared with conventional courses of action in the management ulcerative colitis. The published studies on the use of anti-adalimumab antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect (Morita, et al; Roblin, et al). Additionally, the ATLAS study showed that patients with loss of response may actually have high, rather than low, serum levels (Yarur, et al). Moreover, controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with ulcerative colitis compared with conventional management. For these reasons, the laboratory testing (CPT code 84999) provided on 9/4/17 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 66-year-old female enrollee has requested reimbursement for laboratory testing (CPT code 84999) provided on 9/4/17. 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 records indicate that this patient has ulcerative colitis that has remained severe despite treatment with azathioprine and Humira. An Anser ADA test was performed to help determine the patients course of treatment. Determining a patients Humira levels has become important when a patient loses response to Humira, which may require increasing the dose. In this case, there is concern as the disease is advanced and the patient had already failed several regimens. Determining whether the patient has therapeutic levels and antibodies may point the treating provider toward a different drug or another etiology. Moreover, it has been shown that checking for these antibodies helps optimize clinical response by helping achieve a more optimal drug concentration (Baert, et al; Vande Casteele, et al). 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 1


A 63-year-old male enrollee has requested authorization and coverage for transcatheter radiofrequency ablation. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees paroxysmal atrial fibrillation.   The physician reviewer found that based on the records provided, this patient presents with symptomatic paroxysmal atrial fibrillation and relative contraindication to trials of antiarrhythmic medication due to intermittent bradycardia and pauses. In this circumstance, current guidelines for the management of atrial fibrillation consider catheter ablation appropriate therapy if there is failure or intolerance at least one anti-arrhythmic medication (January, et al; Calkins, et al). Since this patient has relative contraindication to antiarrhythmic medication, proceeding to ablation is reasonable, appropriate and considered standard accepted practice in the medical community. Moreover, this patients symptomatic atrial fibrillation has a more favorable chance of success with ablation since it is paroxysmal. For these reasons, the requested transcatheter radiofrequency ablation 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 service 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.