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

Summary Reviewer 2

The parent of an 11-year-old female enrollee has requested authorization and coverage for gene testing.  The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition.The physician reviewer found the medical evidence supports the requested gene testing in this clinical setting.  In this patients case, her constellation of symptoms may represent atypical Gitelman syndrome or atypical Bartter syndrome.  Gitelman syndrome is an autosomal recessive genetic kidney disorder that results in imbalance of ionic substances in the body such as potassium and magnesium.  Patients may experience weakness and cramping, as well as fatigue, hypotension, and ventricular dysrhythmias.  Bartter syndrome is also an autosomal recessive genetic kidney disorder that results in imbalance of electrolytes in the body.  Patients may experience dehydration, constipation, polyuria, osteopenia, and sensorineural hearing loss.  Identification of the underlying disorder will be beneficial to this patient for future medical management.  Therefore, the requested gene testing is likely to be superior over other methods of evaluating this patient.  Based upon the information set forth above, the requested services are 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 parent of an 11-year-old female enrollee has requested authorization and coverage for gene testing.  The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the patient is an ideal candidate for whole exome sequencing, given her multisystem disease, with short stature, intellectual disability, and renal anomalies (both structural and functional).  These multisystem findings increase the likelihood of an underlying single gene disorder which can be identified by whole exome sequencing.  The identification of a specific diagnosis in this patient may provide guidance for treatment of her renal anomalies and electrolyte abnormalities.  A unifying diagnosis may also provide insight into helpful treatments for growth failure.  Thus, the requested gene testing is likely to be superior over other methods of evaluating this patient.  Based upon the information set forth above, the requested services are 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 Upheld

Summary Reviewer 1

A 49-year-old male enrollee has requested reimbursement for the platelet rich plasma injection performed on 1/4/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for treatment of the enrollees left foot pain. The physician reviewer found the platelet rich plasma injection performed on 1/4/17 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The documentation submitted for review indicates that the patient has failed splinting, oral anti-inflammatory medications, steroid injections, as well as orthotics. Length of time of each treatment, number of injections, and strength of injections is needed to assess whether patient has undergone proper conservative treatment. Furthermore, it does not appear the patient has undergone the standard of care treatments for posterior tibial tendon dysfunction including immobilization and casting. Furthermore, platelet rich plasma injections have demonstrated only mild efficacy for certain pathologies including plantar fasciitis, as well as tendon dysfunctions. Studies advise that further research is needed to fully understand the efficacy of platelet rich plasma, especially in joint pain and arthritis. For the reasons provided, the service at issue was 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 service at issue was 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 49-year-old male enrollee has requested reimbursement for the platelet rich plasma injection performed on 1/4/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for treatment of the enrollees left foot pain. The physician reviewer found there is a lack of peer-reviewed literature supporting the use of PRP injection for the treatment of foot pain. Vannini and colleagues reviewed the medical literature on the clinical application of PRP for the treatment of foot and ankle pathologies. The authors found no clear indications for using PRP in the foot and ankle. For the reasons provided, the PRP injection provided on 1/4/17 was 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 service at issue was 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 49-year-old male enrollee has requested reimbursement for the platelet rich plasma injection performed on 1/4/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for treatment of the enrollees left foot pain. The physician reviewer found the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The medical literature concerning the use of PRP for treatment of musculoskeletal conditions of the foot show mixed results regarding potential benefits of PRP for musculoskeletal conditions. Sampson and colleagues reviewed PRP injections for musculoskeletal injuries, found PRP provides a promising alternative to surgery or other invasive treatment modalities. However, the authors concluded that there are too few controlled trials and sample sizes are too small. Therefore, the authors concluded that more large controlled studies are needed. In sum, there are a lack of peer-reviewed medical literature to conclude that PRP is better than any other standard treatment for musculoskeletal conditions. Therefore, the PRP injection performed on 1/4/17 was 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 service at issue was 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 61-year-old male with a medical history including diabetes mellitus who presented to the emergency department after a bicycle versus car collision, resulting in multiple injuries. His injuries included a non-displaced clavicular fracture, left-sided rib fractures at ribs 4 and 6, a small pneumothorax and a pelvic fracture. The physician reviewer found that at the time of admission, the patient was hemodynamically stable without hypoxia. His pain was controlled. He did not suffer from any open traumatic fractures or head injury. There were no urgent procedures or surgeries required. The laboratory studies were mostly unremarkable, except for a mildly elevated glucose level. The inpatient admission was not medically necessary for this
patient. Inpatient care is necessary when the patientas signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition with improved symptoms and could have been treated at a lower level of care, like observation. He remained stable and did not have any complications that would require inpatient admission. Therefore, inpatient services provided from 10/12/20 through 10/13/20 were not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 43-year-old enrollee has requested reimbursement and prospective authorization and coverage for tobramycin/betamethasone/itraconazole compound from 7/25/16 and 8/3/16 and forward. The Health Insurer has denied this request indicating that the compounded medications were and are considered investigational for treatment of the enrollees chronic sinusitis. The physician reviewer found that there is a lack of evidence in the medical literature to support the superior efficacy of the compounded medications at issue in this clinical setting. While the use of budesonide in a nebulized form in treatment of chronic otherwise refractory rhinosinusitis has gained some acceptance, its use, as well as the use of steroids compounded with antibiotics and/or antifungal medication is off label and unproven in efficacy. There is very limited clinical data to support its superiority over standard forms of therapy. All told, in light of the limited clinical evidence in the literature, tobramycin/betamethasone/itraconazole compound administered on 7/25/16 and 8/3/16, forward was not, and is not likely to be more effective than the standard therapies available for treatment of this patients medical condition. Therefore, for the reasons stated above, the compounded medications were not and are not likely to have been 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 43-year-old enrollee has requested reimbursement and prospective authorization and coverage for tobramycin/betamethasone/itraconazole compound from 7/25/16 and 8/3/16 and forward. The Health Insurer has denied this request indicating that the compounded medications were and are considered investigational for treatment of the enrollees chronic sinusitis. The physician reviewer found that the patient has history of chronic sinusitis and has had problems despite multiple medical therapies. The patient has undergone surgery and the provider has requested topical antibiotic/steroid/antifungal for treatment. However, the combination of tobramycin/betamethasone/itraconazole compound has not been found to be more efficacious than standard therapy of saline in treating chronic sinusitis. There is a lack of support in the medical evidence indicating the superior efficacy of the compounded medications over standard options. Saline irrigation is the standard of care in treating chronic sinusitis after surgery. In sum, tobramycin/betamethasone/itraconazole compound administered on 7/25/16 and 8/3/16 and forward was not and is not likely to be superior to the available standard options for treatment of this patient. Therefore, for the reasons stated above, the compounded medications were not and are not likely to have been 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 43-year-old enrollee has requested reimbursement and prospective authorization and coverage for tobramycin/betamethasone/itraconazole compound from 7/25/16 and 8/3/16 and forward. The Health Insurer has denied this request indicating that the compounded medications were and are considered investigational for treatment of the enrollees chronic sinusitis. The physician reviewer found that there is some support for the efficacy of the compounded medications in this clinic setting. Chronic rhinosinusitis (CRS) is a highly prevalent disease in the adult and pediatric population. Although oral medications are effective in controlling some symptoms, they are associated with side effects and long-term use is not ideal. Thus, topical therapies have emerged as an alternative delivery method for localized, high-concentration medication with less side effects. Topical saline and intranasal steroids appear to consistently demonstrate therapeutic benefits, as evidenced by significant clinically relevant improvements and lack of serious side-effects. Nasal sprays and nasal irrigation are common delivery options for topical steroids. Physiologic saline irrigation is beneficial in the treatment of symptoms of CRS. In this case, low-level evidence supports the effectiveness of topical antibiotics in the treatment of CRS. Therefore, it is reasonable to continue additional therapy with nasal irrigations in this patient, who is status post sinus surgery and has been treated with multiple rounds of antibiotics. As such, tobramycin/betamethasone/itraconazole compound administered on 7/25/16 and 8/3/16 forward was and is likely to be more effective than the available standard options for treatment of this patients medical condition. Therefore, for the reasons stated above, the compounded medications were and are likely to have been 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 Overturned

Summary Reviewer 

A 34-year-old female enrollee has requested authorization and coverage for Xyrem 500 mg/ml oral solution. 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 there is sufficient support for the requested services in this clinical setting. The patient was accurately diagnosed with narcolepsy without cataplexy. Her symptoms were not controlled with several stimulant medications. The patient has excessive daytime sleepiness, which responded to Xyrem. Xyrem has been approved by the U.S. Food and Drug Administration for the treatment of patients with narcolepsy type 2. Continuation of Xyrem treatment is critical to control this patients narcolepsy. Therefore, Xyrem 500 mg/mL oral solution is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 43-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/8/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic as to her breasts. The physician reviewer found that this patient is a 43-year-old female who had a bilateral screening mammogram with tomosynthesis on 8/8/16. There were scattered fibroglandular elements in both breasts. The impression was negative. The patient requested reimbursement for the breast tomosynthesis performed on 8/8/16. The Health Insurer denied the request for reimbursement. Per the Health Insurer, the service at issue was investigational for the evaluation of this patient. The medical literature supports breast tomosynthesis in this clinical setting.  Per 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 state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus the literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis performed on 8/8/16 was likely to have been superior to other methods of evaluating this patient. Based upon the information set forth above, the service 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 2

A 43-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/8/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic as to her breasts. The physician reviewer found that the patient is a 43-year-old asymptomatic female who was evaluated with screening mammogram and digital breast tomosynthesis on 8/8/16. This study revealed no evidence of malignancy. The Health Insurer has denied reimbursement of digital breast tomosynthesis performed on 8/8/16. Per the Health Insurer, the service at issue was investigational for the evaluation of this patient. There is evidence based support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis, to the usual two dimensional protocol on 8/8/16 was likely to be more effective than had the patients examination been performed using two dimensional imaging alone. Based upon the information set forth above, the service 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

A 43-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/8/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic as to her breasts. The physician reviewer found that the patient is a 43-year-old female who was asymptomatic with respect to her breasts.  Her immediate breast history dates back to 4/3/15 when she had a screening mammogram that demonstrated a suspicious nodule in the right breast.  After the 4/3/15 mammogram, she was recalled for additional imaging including compression views on 5/5/15, and the nodule persisted.  Following the 5/5/15 study, it was recommended that a sonogram be performed.  The results of the sonogram were not submitted. She returned on 8/8/16 for a screening mammogram, and no significant abnormalities were detected.  The 8/8/16 study consisted of a combination two dimensional and three dimensional tomosynthesis study. This study was compared to prior mammograms. There were no masses, areas of suspicious calcifications, or areas of architectural distortion. Her breast tissue was described as containing scattered fibroglandular elements. The Health Insurer denied reimbursement noting that the service at issue was investigational for the evaluation of this patient. 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 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 particular patient, there was an abnormality on her mammograms in 2015 that warranted further attention.  It is unclear what the outcome was after those evaluations, but since no mention was made of a biopsy, it is reasonable to conclude that the sonogram revealed either nothing, or more likely, a cyst.  In either of those two settings, it is not unreasonable to perform a tomosynthesis as a follow-up study.  As mentioned above, tomosynthesis offers the advantage of separating out overlapping structures and can better delineate the margins of a suspected mass or cyst.  As this is the first follow-up after detection of a mass, digital breast tomosynthesis performed on 8/8/16 was more likely to have been more effective than other methods of evaluating this patient.  Based upon the information set forth above, the service 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 38-year-old male enrollee has requested authorization and coverage for cardiac resynchronization therapy. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee, who has a history of sarcoidosis and myocardial involvement. The physician reviewer found that in patients with cardiac sarcoidosis and ejection fraction greater than 35% who have an indication for pacemaker placement, it is reasonable to implant a defibrillator if meaningful survival of greater than one year is expected, such as with this patient.  Since 2:1 atrioventricular block is continuous in this case, the patient will be right ventricular paced about 50% of the time once a pacemaker has been placed, raising a concern for chronic right ventricular pacing induced left ventricular dysfunction. There is some data to demonstrate worsening left ventricular dysfunction as a result of chronic right ventricular pacing, but only in patients with a history of heart failure and ejection fraction less than or equal to 50%, neither of which this patient has. Therefore, given this patients ejection fraction and no documented heart failure, biventricular pacing is not medically necessary. Thus, cardiac resynchronization therapy is not medically necessary 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

A 43-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 2/14/18. 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 is classically evaluated by the staging system spelled out by Balch. Mitotic rate may add to these statistics. DecisionDx-Melanoma testing is a 31-gene panel 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 DecisionDx-Melanoma classification and prognosis, in patients who had had sentinel node biopsy. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch statistics. Most importantly, it is not clear if DecisionDx-Melanoma testing can be used to make clinical decisions. Therefore, DecisionDx-Melanoma testing performed on 2/14/18 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.