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

Summary Reviewer 

A 45-year-old female enrollee has requested reimbursement and prospective authorization and coverage for IVIG (Octagam) from 4/29/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollee, who has symptoms of distal sensory paresthesias, fatigue and weakness in the lower extremities. The physician reviewer found that the medical literature support the services at issue in this clinical setting. Although IVIG is not indicated for all cases of neuropathy, it is indicated for patients diagnosed with CIDP and in some cases, those patients with autoimmune disease.  In this particular case, the patient carries the diagnosis of CIDP and has had a reported benefit of her clinical symptoms in response to this therapy.  The medical literature demonstrates the benefit of IVIG in patients with CIDP. To undertreat an autoimmune neuropathy would place the patient at risk of significant clinical decline and functional impairment.  In this patients case, the continued use of IVIG is medically indicated, given her medical history. As such, IVIG (Octagam) from 4/29/16 forward was and is medically necessary. Therefore, for the reasons stated above, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 63-year-old male enrollee has requested reimbursement and prospective authorization and coverage for Avastin injections from 2/27/14 forward.  The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found the current medical evidence does not support the services at issue in this clinical setting.  The use of Avastin has been well studied as an adjunct to chemotherapy in pancreatic cancer.  Kindler and colleagues reported a study of 602 patients with pancreatic cancer treated with either Gemzar or Gemzar with Avastin.  The authors noted that the addition of Avastin did not improve survival in advanced pancreatic cancer patients.  Van Cutsem and colleagues reported on 607 patients randomized to chemotherapy with or without Avastin.  The authors reported that there was no significant difference in overall survival with the use of the Avastin.  All told, Avastin injections from 2/27/14 forward were not and are not medically indicated for the treatment of this patient.  Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

[INSERT FIRST TWO SENTENCES FROM SUMMARY REVIEW DETERMINATION] The physician reviewer found that pooled results of two large, randomized, placebo-controlled trials demonstrated that Botox is an effective, safe, and well-tolerated treatment for the prevention of headache for patients with chronic migraine (Aurora, et al). Further, the U.S. Food and Drug Administration (FDA) approved Botox for headache prophylaxis in patients with chronic migraine with headaches on 15 or more days per month, each lasting more than four hours. To treat chronic migraine, Botox is given approximately every 12 weeks as multiple injections around the head and neck to try to dull future headache symptoms. The available medical records document the patient has failed at least two medications for migraine prophylaxis. In addition, the patients chronic migraine headaches occurred more than 15 days per month, lasting four or more hours, for at least three months. Given these findings, the Botox injections (CPT code 64615) provided on 5/26/17, 8/25/17, and 11/17/17 were 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 services at issue were 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

[INSERT FIRST TWO SENTENCES FROM SUMMARY REVIEW DETERMINATION] The physician reviewer found that botox is considered within the standard of care for patients with chronic migraine. Botox has also been approved by the U.S. Food and Drug Administration (FDA) to treat chronic migraine. In the peer-reviewed medical literature, Dodick and colleagues concluded that Botox is an effective and well-tolerated prophylactic treatment in migraine patients with CDH [chronic daily headache] who are not using other prophylactic medications. This patient has reportedly tried and failed gabapentin, which is an anticonvulsant, as well as nortriptyline and duloxetine, which are antidepressants. The patient is noted to have chronic daily migraine with zero headache free days at baseline. Accordingly, the Botox injections (CPT code 64615) provided on 5/26/17, 8/25/17, and 11/17/17 were 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 services at issue were 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

[INSERT FIRST TWO SENTENCES FROM SUMMARY REVIEW DETERMINATION] The physician reviewer found that botox is a U.S. Food and Drug Administration (FDA) approved treatment for the treatment of migraines (Escher, et al). Botox is indicated for the treatment of chronic headaches in patients who have at least 14 headache days per month. In the peer-reviewed medical literature, Aurora and colleagues concluded that repeat treatment with five or fewer cycles of Botox was effective, safe, and well tolerated in adults with chronic migraine. This patient is documented to have daily migraine that has been refractory to standard migraine medications. Based on a review of the patients medical records and the current medical literature, the Botox injections (CPT code 64615) provided on 5/26/17, 8/25/17, and 11/17/17 were 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 services at issue were 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 

The parent of a nine-year-old female enrollee has requested authorization and coverage for chromosomal microarray analysis.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found that Microarray is a first-line test in the evaluation of children with intellectual disability/developmental delay, autism spectrum disorder, or multiple congenital anomalies. This patient falls into a category of patient for whom microarray is recommended as a first line investigation. Microarray technology has evolved over the years, initially being done using bacterial artificial chromosomes (BAC) and now being done with oligonucleotides and single nucleotide polymorphisms. The patient has previously had a microarray, but the results were not provided and the details of the methodology used are not given. In order to determine if a chromosomal microarray analysis is superior to what was done previously, a comparison of the methodologies is needed.  Additionally, it is noted that the initial microarray showed a maternally-inherited chromosome 16 deletion which was interpreted as nonsignificant. Interpretation of a chromosomal microarray finding may change over time as new information regarding significance of copy number variations becomes available (Palmer, et al). Therefore, the appropriate next step is to have this patients prior microarray results reviewed by a clinical geneticist who can re-evaluate the medical literature associated with the chromosome 16 deletion to determine if there has been a change in interpretation of pathogenicity, and decide, based on this information and comparing the methodology of the previous microarray and the proposed new testing, whether a new study is needed. Therefore, the requested services are 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 an 11-year-old female with short stature. The patientas parent has requested authorization and coverage for Nutropin AQ Nuspin. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. This patient was growing along the 5th percentile from age 4 years and was subsequently started on growth hormone therapy. She has a good IGF-1 generation on growth hormone treatment. This patient exhibited signs of growth failure before the growth hormone treatment was started. Per the submitted documentation, she had a good response to growth hormone therapy in terms of growth velocity. Continuation of growth hormone therapy is medically appropriate in this case. Therefore, Nutropin AQ Nuspin is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 52-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene expression testing performed on 11/01/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has been thought to add a bit to the statistics. DecisionDx-Melanoma gene expression testing is a study of 31 genes in the cells of an individuals melanoma. It then classifies the melanoma based on the five-year risk of metastases. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma class, in patients having sentinel node biopsy. Berger reported on 156 cases, but there was not sufficient follow-up to determine the clinical value of the assay. It is not known how the five-year DecisionDx-Melanoma data compares and relates to the 10-year Balch data. Most importantly, it is not clear if the DecisionDx-Melanoma class can be used to make clinical decisions. Therefore, DecisionDx-Melanoma gene expression testing performed on 11/01/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 52-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene expression testing performed on 11/01/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines states that while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. There is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. In sum, DecisionDx-Melanoma gene expression testing performed on 11/01/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 52-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene expression testing performed on 11/01/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with a high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma gene expression testing has not made it part of routine analysis after sentinel lymph node biopsy. There has been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma gene expression testing performed on 11/01/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

The patient is a 19-year-old female with cannabis use disorder, opioid use disorder, unspecified anxiety disorder and unspecified depressive disorder. She had presented with impaired functioning including school truancy and alienation/withdrawal socially. She was unable to maintain sobriety and was reported to make dangerous decisions. Outpatient treatment had failed and her providers recommended treatment in a residential recovery program. The patient has requested reimbursement for mental health residential treatment services provided from 1/20/17 through 4/19/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. The American Psychiatric Association (APA) treatment guidelines state that residential treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use. In addition, Handwerk and colleagues found that residential treatment has been shown to be particularly effective in reducing adolescent girls feelings of hopelessness, negative self-evaluation, and suicidal ideation. The records document that this patient needed residential treatment as demonstrated by her inability to maintain sobriety and functioning using outpatient modalities. Residential treatment was in accordance with generally accepted standards of medical practice and the APA guidelines. All told, the mental health residential treatment services provided from 1/20/17 through 4/19/17 were medically necessary for treatment of this patients medical condition.  Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 32-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees asthma.  The physician reviewer found that the records and peer-reviewed medical literature suggest that this patient may benefit from the requested bronchial thermoplasty. The procedure was approved by the U.S. Food and Drug Administration (FDA) in 2010 for the treatment of severe persistent asthma in adults not well controlled with inhaled corticosteroids and long acting beta-agonists. The literature shows that bronchial thermoplasty would be beneficial to this patient in decreasing the number of exacerbations requiring prednisone orally, the need for rescue treatment such as albuterol, and improving her daily symptoms. The treatment has been shown to be safe up to five years after treatment per AIR 2 trial (Castro, et al). This patient meets the criteria with severe persistent asthma uncontrolled by maximal medical treatment. In addition, no other pulmonary condition is documented to explain her condition other than bronchial asthma and her pulmonary function tests fall in the category of moderate obstructive airway obstruction. For these reasons, the requested bronchial thermoplasty is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the requested procedure 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 Overturned

Summary Reviewer 2

A 32-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees asthma.  The physician reviewer found that the current medical literature supports the use of bronchial thermoplasty in patients with severe persistent asthma that has not responded to adequate trials of medical therapy. The use of bronchial thermoplasty in well selected patients has resulted in reduced exacerbations, fewer emergency department visits, and improved quality of life. All told, the scientific data supports the safety and effectiveness of the requested bronchial thermoplasty as likely to be more beneficial for this patients medical condition than treatment with any available standard therapy. Based upon the information set forth above, I have determined the requested procedure 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 Overturned

Summary Reviewer 3


A 32-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees asthma.  The physician reviewer found that Bronchial thermoplasty is a procedure that uses a bronchoscope probe/catheter to provide thermal energy to the smooth muscle of the airway. There are three bronchoscopy procedures. The first treats the right lower lobe. The second treats the left lower lobe and the third procedure is for both upper lobes. The procedures are scheduled about three weeks apart. However, bronchial thermoplasty is not generally accepted as the standard of care for the treatment of asthma. There is inadequate scientific data demonstrating an increase in forced expiratory volume (FEV)-1 with this treatment. In addition, a recent publication noting the safety of the procedure did not report any difference in FEV-1 or in the frequency of emergency department visits or hospital admissions, between the bronchial thermoplasty group and the control group (Thompson, et al). Overall, the peer-reviewed medical literature indicates the requested bronchial 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, I have determined the requested procedure 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a nine-year-old female who has been diagnosed with phonological disorder. The patientas parent has requested reimbursement for speech therapy provided from 1/04/19 through 12/25/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. Law and colleagues examined the effectiveness of speech and language interventions for children with primary speech and language delay/disorder. The authors reviewed twenty-five studies in their meta-analysis, concluding that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. The American Speech-Language-Hearing Association guidelines note, aPhonological/language-based approaches target a group of sounds with similar error patterns, although the actual treatment of exemplars of the error pattern may target individual sounds. Phonological approaches are often selected in an effort to help the child internalize phonological rules and generalize these rules to other sounds within the pattern (e.g., final consonant deletion, cluster reduction).a Wren and colleagues noted, aChildren with persistent speech disorder (PSD) are at higher risk of difficulties with literacy, with some evidence suggesting an association with poorer educational attainment.a There is sufficient support for the services at issue in this clinical setting. Therefore, speech therapy provided from 1/04/19 through 12/25/20 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 41-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/26/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add to these statistics. An additional methodology in looking at the prognosis is a molecular assay, DecisionDx-Melanoma testing. This looks at the molecular and genetic aspects of an individualas melanoma cells, and then classifies that melanoma based on the five-year risk of metastasis. It is not clear how the five year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it has not been shown that one can use DecisionDx-Melanoma classification to make clinical decisions. In this case, the fact that the melanoma is greater than 1.0 mm, places it in a category for which sentinel node biopsy is recommended. DecisionDx-Melanoma testing does not add to this decision making. Therefore, DecisionDx-Melanoma testing performed on 5/26/20 was not likely to have been more beneficial than any available standard therapy.