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

Summary Reviewer 2
A 51-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 9/29/20. 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 Guardant360 is a multigene and mutational assay done on the DNA found in the blood, presumably shed by metastatic cancer cells. This testing can be used instead of a tissue assay when it is not possible or safe to do a biopsy. There are certain situations where such mutational assay has been useful in selecting therapy, e.g., in non-small cell lung cancer. However, its overall use in predicting which agent might be useful has not been convincingly shown. A randomized study by Le Tourneau and colleagues did not demonstrate advantage to selecting treatment based on an assay versus the oncologistas judgment. As noted by Marquart and colleagues, the percentage of patients who benefit from such an approach appears to be low. In this particular case, a genomic assay had previously been done on the metastatic disease (Foundation One assay). It appears the oncologist ordered Guardant360 as a re-check on the Foundation One findings. There is a lack of real data indicating that the Guardant assay can reliably be used for that purpose. Overall, there is a lack of data to suggest that the Guardant assay is likely to be of clinical benefit in this setting. Therefore, Guardant360 testing performed on 9/29/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 51-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 9/29/20. 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 understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing prognostic information, the value of next generation sequencing (NGS) to predict candidates for specific mutation-driven treatment holds promise. Patients with inflammatory and metastatic breast cancers benefit from NGS to identify markers that may indicate benefit from targeted treatment or clinical trials. The use of NGS, such as with Guardant360, is likely to be more effective than available standard therapy. Therefore, Guardant360 testing performed on 9/29/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 63-year-old male enrollee has requested authorization and coverage for spine surgery. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees back pain. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. A review of the literature indicates evidence of good outcomes from decompression and lumbar fusions for chronic pain with or without instability, spinal stenosis and spondylolisthesis. In this case, in the presence of severe spinal stenosis and severe neural foraminal stenosis at L3-4, a wide decompression is needed. This will necessitate removal of hypertrophic facets which will lead to iatrogenic instability, necessitating a fusion procedure for stabilization. Spondylolisthesis is a known cause of instability which makes the fusion even more necessary. All told, the requested spine surgery is medically necessary for the treatment of this patient. Therefore, the requested services 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 45-year-old male enrollee has requested authorization and coverage for Xyrem. 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 fails to demonstrate the medical necessity of the requested medication. This patient was diagnosed with narcolepsy in 2015 by a multiple sleep latency test (MSLT), which was preceded by an overnight polysomnography sleep study. After reviewing the result of the sleep study and MSLT, these studies were inconclusive and technically inadequate. The patient slept only 228 minutes, while at least 360 minutes is required per American Academy of Sleep Medicine guidelines to have adequate MSLT test results. In addition, the MSLT showed an average sleep latency of 9 minutes and 48 seconds, while the guidelines for positive MSLT is less than 8 minutes. The results from his sleep studies cannot be considered adequate to support the diagnosis of narcolepsy. Xyrem is indicated to treat appropriately diagnosed narcolepsy patients with or without cataplexy if there is contraindication or poor response to other medications. There is a lack of support for the requested medication in this clinical setting. Therefore, Xyrem is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 12-year-old female who was seen by a pediatric endocrinologist on 12/14/20. Her height was 146.0 cm, which is below the 35th percentile or -0.41 standard deviations below the norm for age and gender. The patientas parent has requested authorization and coverage for Norditropin FlexPro 30 mg/3 mL. 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 the submitted documentation supports the medical necessity of the requested medication. The records support poor growth, short stature relative to the mid-parental height and growth hormone deficiency. The records document deceleration from the 75th to the 50th percentile in height between 4 and 6 years of age, after which her height had gone down to the 50th percentile and stayed at the 50th until she was seen by the endocrinologist. On the day of visit, the patientas height was 146 cm (34th percentile). The mid-parental target height is 171.45 cm. Her predicted adult height is 62.75a, which is -2 standard deviations below the genetic mean height. She has failed an initial clonidine stimulation test as well as a second stimulation test. Brain MRI noted asmall appearing concave pituitary gland measuring up to 3.7 mm in maximal height.a Small pituitary gland can be seen in growth hormone deficiency and panhypopituitarism. Growth hormone therapy is medically indicates in this setting. Growth hormone deficiency was the first indication for recombinant human growth hormone approved by the U.S. Food and Drug Administration (FDA). In this case, the records document growth hormone deficiency upon performing the stimulation test. Therefore, Norditropin FlexPro 30 mg/3 mL is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 63-year-old male enrollee has requested reimbursement for laboratory testing performed on 2/11/19. 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 supports the services at issue in this clinical setting. MRD has been found to be a strong prognostic indicator in patients with mantle cell lymphoma. Patients with a negative PET and no MRD have better five-year overall survival rates. Testing for MRD has been used to guide indications for additional therapy, such as maintenance rituximab and autologous stem cell transplant. Achievement of MRD negativity was also associated with improved clinical outcomes. Therefore, laboratory testing (unlisted molecular pathology) performed on 2/11/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 




A 49-year-old female enrollee has requested authorization and coverage for the Flexitouch pneumatic compression pump. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees lymphedema swelling status post mastectomy. The physician reviewer found that the Flexitouch pneumatic compression system is not medically necessary for diagnosis and treatment of this patients medical condition. A review of the literature reveals that there is insufficient evidence to recommend the Flexitouch pneumatic compression system over conventional lymphedema pumps. Wilburn and colleagues compared the Flexitouch with conventional maintenance therapy and revealed that further investigation was needed. Ridner and colleagues reported that the positive results suggest that further investigation will be useful. Fife and colleagues compared treatment with the Flexitouch system with the Biocompression Systems Sequential Circulator. The authors reported statistically significant between-group differences in two of these both favoring treatment with the Flexitouch system. However, the study by Fife and colleagues was limited by its small sample size, missing data on the local tissue water outcome, and unclear blinding of outcome assessment. Additionally, the outcomes reported were primarily volume of fluid removed, which is an intermediate outcome. Pilch and colleagues compared lymphedema pumps in terms of number of chambers and cycle times and noted that overall there was not a significant difference among groups. Without sufficient evidence in the literature for the requested device and without evidence of failed conservative management, the requested Flexitouch pneumatic compression pump is not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested device is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 32-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 4/12/21. 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 patients with vaginitis can be evaluated and treated with an examination, microscopy and/or cultures, depending on the patientas symptoms and findings. The exact process depends on the provider and the resources available at that particular office. This patient reported a fishy odor, and the provider noted white discharge on examination. The medical evidence supports the services at issue in this patientas case. The services at issue were standard of care option and are clinically appropriate, especially when the history and examination do not coincide. Therefore, polymerase chain reaction testing performed on 4/12/21 was likely to have been more beneficial for evaluation of the patientas condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 32-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 4/12/21. 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 polymerase chain reaction testing is likely to have been more beneficial than any available standard therapy in this case. For a patient who presents with symptoms of abnormal vaginal discharge, an examination of the vaginal discharge, including microscopic evidence of infection, can lead to a definitive diagnosis. In the case, where microscopy is not available, commercial diagnostic testing methods, including polymerase chain reaction, are used for confirming the clinical suspicion of bacterial vaginosis, vaginal candidiasis, or trichomonas vaginitis. Furthermore, polymerase chain reaction testing can be utilized for detecting both gonorrhea and chlamydia. Microscopy is no longer widely available in clinic settings, and practices are now relying on this testing to diagnose and treat vaginitis. Current studies reported sensitivities and specificities of over 96 percent for the detection of Neisseria gonorrhoeae and Chlamydia trachomatis. Therefore, polymerase chain reaction testing performed on 4/12/21 was likely to have been more beneficial for evaluation of the patientas condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3
A 32-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 4/12/21. 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 polymerase chain reaction testing has been compared to traditional testing for vaginitis. The literature supports the use of polymerase chain reaction testing because it results in significantly higher sensitivity and negative predictive value than clinical diagnosis or clinical testing.  The test was also superior for detecting more than one cause for vaginitis. The medical evidence supports polymerase chain reaction testing as a means of accurate detection which allows for appropriate treatment. Therefore, polymerase chain reaction testing performed on 4/12/21 was likely to have been more beneficial for evaluation of the patientas condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 31-year-old female enrollee has requested authorization and coverage for Avastin. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found central nervous system tumors are classified by the WHO based on their proliferative potential, morphology, and molecular genetics and are conferred grades I-IV. Glioblastoma multiforme are high grade tumors that are best treated with resection, radiation therapy, and chemotherapy. Most GBM tumors recur and then the treatment options are limited. In this case, the patient has had a recurrence. Avastin is medically necessary and approved by the U.S. Food and Drug Administration (FDA) for recurrent GBM (Cohen, et al). Its use in this clinical setting is consistent with FDA approval and strongly supported by medical evidence. Therefore, Avastin is medically necessary for treatment of the patients medical condition. For the reasons provided, 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 

A 49-year-old female enrollee has requested authorization and coverage for Ubrelvy. 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 a history of chronic migraine, and she has failed traditional migraine treatments. The provider notes that the patient had modest benefit with the use of triptan medications. The current method of treating intractable migraine headaches, especially during acute attacks, is the use of medications with various mechanisms of action. Since triptans are somewhat effective for this patient, the use of a calcitonin gene-related peptide (CGRP) antagonist such as Ubrelvy is likely to provide added benefit, since there is a different mechanism of action. There is sufficient support for the requested medication in this clinical setting. Therefore, Ubrelvy is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 14-year-old male with moderately severe Crohnas disease associated with poor growth, diarrhea, nocturnal stooling, fatigue, and perianal disease with fissures and tags. The patientas parent has requested authorization and coverage for Inflectra procedure code Q5103 starting dose 7.5 mg/kg and treatment at a hospital affiliated infusion center. The Health Insurer has denied this request and reported that the requested medication and services are not medically necessary for the treatment of this patient. The physician reviewer found that adequate trough concentrations of infliximab during the induction phase are associated with better outcomes in both adults and children with Crohnas disease. Unfortunately, sub-therapeutic infliximab levels are common, leading to a need to measure drug concentrations carefully at the end of the induction period. Alternate dosing strategies have also been considered. At this time, there have not been head-to-head trials comparing standard (5 mg/kg/dose) to higher-dose infliximab induction regimen.  However, pharmacokinetic modeling studies have identified factors associated with lower trough levels. The recent study by Xiong and colleagues found predictors of sub-therapeutic infliximab exposure to include age less than 10 years, ESR greater than 30 mm/h, weight less than 30 kg, and neutrophil CD64 activity ratio greater than 6. This patient meets one of these parameters (ESR), although his neutrophil CD64 activity ratio, which is not a standard clinical measurement, is not known. European consensus guidelines state that factors indicating higher dosing are similar, including extensive disease and low serum albumin levels, which are not present in this patient.  Considering his clinical picture, higher dose infliximab induction is not indicated. The patientas provider has requested that induction doses be given in a hospital-based infusion center, and the Health Insurer has already agreed to cover the first two inductions at that location. Data on outcomes for children receiving infliximab infusions at non-hospital-based infusion centers are limited, although the practice has been described in the pediatric gastrointestinal literature. In the paper by Gupta and colleagues, over 40% of patients receiving infliximab infusions were not deemed to be appropriate candidates for non-hospital-based infusions by their medical providers. This patient does not have any obvious disqualifications for home infusion (e.g. poor vascular access). It is possible that such a characteristic will be identified during the first two infusions, in which case the question can be reconsidered. In the meantime, transition to home or independent infusion center infusions would be expected to be appropriate, for the third induction dose and maintenance dosing, assuming that the home health agency or infusion center is able to provide pediatric-trained staff. In sum, Inflectra procedure code Q5103 starting dose 7.5 mg/kg and treatment at a hospital affiliated infusion center are not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 35-year-old male enrollee has requested authorization and coverage for 64568 and 0466T. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the Inspire hypoglossal nerve stimulation (HNS) device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of moderate to severe obstructive sleep apnea refractory to continuous positive airway pressure (CPAP). However, a meta-analysis by Kompelli and colleagues found that contemporary HNS research consisted of single-arm clinical trials and case series, with a high likelihood of publication bias and a lack of comparative trials of HNS versus existing alternatives such as upper airway surgery. They concluded that HNS may not be the definitive choice for second line therapy for obstructive sleep apnea. In this case, clinical encounter notes did not mention uvulopalatopharyngoplasty (UPPP) or oral/dental appliances as options, despite physical examination findings that appeared to involve primarily the soft palate. Overall, there is insufficient high-quality, peer-reviewed evidence to support the use of HNS over other available therapies. Therefore, 64568 and 0466T are not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 35-year-old male enrollee has requested authorization and coverage for 64568 and 0466T. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the patient has obstructive sleep apnea and has no nasal obstruction. Drug-induced sleep endoscopy showed no concentric collapse at velum and primarily anterior posterior collapse. The patient has not been able to tolerate the CPAP device. The Inspire device has been approved by the FDA for the treatment of obstructive sleep apnea. At this point, the patient is a candidate for the Inspire device, given the intolerance to CPAP, anterior posterior collapse, no central apnea, and body mass index (BMI) and apnea-hypopnea index (AHI) within FDA criteria. All told, 64568 and 0466T are likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 35-year-old male enrollee has requested authorization and coverage for 64568 and 0466T. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient has already failed CPAP therapy. Multiple studies have demonstrated that hypoglossal nerve stimulation or Inspire airway stimulation improves health for people with obstructive sleep apnea with clinically significant decreases in observed mean apnea-hypopnea index and improvements in quality of life. The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be a safe and effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy. The International Surgical Sleep Society Position Statement states hypoglossal nerve stimulation has been shown to be effective in the treatment of sleep disordered breathing/obstructive sleep apnea in adults when applied to selected patients based on their anatomy, physiology, BMI and neck size, prior therapy and comorbidities. The medical evidence supports the requested services in this clinical setting. Thus, 64568 and 0466T are likely to be more beneficial than any available standard therapy.