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

Summary Reviewer 2


A 59-year-old male enrollee has requested reimbursement for advanced lipoprotein testing provided on 3/11/16. The Health Plan has denied this request indicating that the service at issue was considered investigational for the enrollees hypertension.The physician reviewer found that based on the documentation provided for review the patient presents with significant cardiovascular risk, including diabetes. 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 (Greenland, et al; Stone, et al). Treatment change 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. Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Accordingly, the advanced lipoprotein testing provided on 3/11/16 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 59-year-old male enrollee has requested reimbursement for advanced lipoprotein testing provided on 3/11/16. The Health Plan has denied this request indicating that the service at issue was considered investigational for the enrollees hypertension. The physician reviewer found there is a lack of support in the peer-reviewed medical literature demonstrating that lipoprotein testing is more beneficial than standard therapy. Advanced lipoprotein testing has not been shown in the scientific data to definitively improve health outcomes compared to the use of standard lipid profiles utilized to make therapeutic lipid lowering decisions. For the reasons stated above, the advanced lipoprotein testing performed on 3/11/16 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 Overturned

Summary Reviewer 1

A 47-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 4/24/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that there is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. Skaane and colleagues performed a large prospective screening trial To assess cancer detection rates, false-positive rates before arbitration, positive predictive values for women recalled after arbitration, and the type of cancers detected with use of digital mammography alone and combined with tomosynthesis. The authors concluded that 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. Given the support in the medical literature, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients breast exam than conventional mammogram is due to improved cancer detection rate.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 47-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 4/24/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that The American College of Radiology (ACR) statement on breast tomosynthesis has urged that tomosynthesis be removed from the investigational category due to the marked advantages it brings radiologists in the interpretation of mammograms resulting in a decrease in callbacks and increase in detection of small cancers. In addition, tomosynthesis is approved by the U.S. Food and Drug Administration (FDA) for clinical use. For these reasons, the addition of tomosynthesis to the usual two-dimensional (2D) protocol was likely of more benefit to this patient than had the exam been done with 2D technique only. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 47-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 4/24/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that 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 (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. In this clinical setting, a breast tomosynthesis would be valuable in determining whether an area of asymmetry warrants a biopsy. However, the standard modalities would be more beneficial as the interpreting radiologist requested the old studies. There is always considerable variability in the appearance of breasts, and the most valuable tool is for the radiologist to compare the current study in question with old mammograms. In this case, the tomosynthesis provided 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 services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 34-year-old male enrollee has requested reimbursement and prospective authorization and coverage for mental health inpatient services provided from 6/30/16 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 enrollees depression, substance dependence, and suicidality. The physician reviewer found that in the medical literature, services are custodial when they do not require continued administration by trained medical personnel. Sharfstein noted that crisis stabilization, safety, and a focus on rapid discharge are the critical components of the acute inpatient stay. Although this patient indicated after detoxification that he would attempt suicide via jumping off a bridge if he were discharged from acute hospital level of care, by 6/30/16 the patient no longer endorsed suicidal ideation and was in no acute distress. The statements made by the patient indicate that he has insight into his substance use disorder and longstanding family conflict. Overall, there is a lack of documentation that the patients needs cannot be met in a less restrictive treatment setting. Accordingly, there is a lack of medical necessity for the 24-hour registered nurse on-site and 24-hour physician on-call services provided by acute inpatient hospital level of care from 6/30/16 forward for treatment of this patients medical condition. Based on these findings, 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 Upheld

Summary Reviewer 1

A 59-year-old male enrollee has requested reimbursement for platelet-rich plasma injections provided from 7/14/17 forward. The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that the intra-articular injections of platelet-rich plasma are known to be beneficial in patients with early osteoarthritis as well as advanced osteoarthritis of the knees and other joints. These injections are known to be more efficacious in the treatment of knee osteoarthritis in terms of pain relief and self-reported functional improvement at three, six and 12 months follow-up, compared with other injections such as corticosteroid injections. No harmful effects are reported from these injections. However, in this case, the medical records do not include sufficient clinical and radiographic information necessary to support the necessity of such treatment in the multiple joints that were injected. A detailed history and physical examination and imaging studies are generally necessary to make an accurate diagnosis and determine the necessity of invasive treatment. Official radiology reports indicating the presence of osteoarthritis necessitating such treatment have not been included. In the absence of such clinical and radiographic findings, platelet-rich plasma injections in various joints is not supported. Additionally, the documentation does not indicate a positive sacroiliac diagnostic block confirming the pain source. Ultrasound or fluoroscopic guidance is generally used for sacroiliac injections. However, there is no documentation of the same. With regard to the trapeziometacarpal joints of the thumbs, the literature suggests efficacy in early osteoarthritis, but not in advanced cases. As such, x-rays are necessary. All told, the superior efficacy of platelet-rich plasma injections provided from 7/14/17 forward has not been established. Based upon the information set forth above, the services at issue were not and are 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 59-year-old male enrollee has requested reimbursement for platelet-rich plasma injections provided from 7/14/17 forward. The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that there is current evidence-based medical guideline and literature support for the treatment of significantly symptomatic osteoarthritis of the knee when specific criteria have been met, including failed conservative treatment (including intraarticular steroids), osteoarthritis that was not advanced, and age under 50 years. Repeat platelet-rich plasma injections are only supported once a year if previous injection provided significant relief for over six months. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of platelet-rich plasma in the treatment of sacroiliac joint pain and wrist/hand disorders. In this case, there is no documentation as to the severity of the reported osteoarthritis of the patients right knee, details of prior conservative treatment failure, and rationale for exception to recommended age limits. There is no compelling rationale presented to support the necessity of platelet-rich plasma injections for the sacroiliac joint or bilateral hands/thumbs in the absence of evidence-based medical literature support. Therefore, platelet-rich plasma injections provided from 7/14/17 forward were not and are not likely to be of greater benefit than other available treatment options. Based upon the information set forth above, the services at issue were not and are 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 59-year-old male enrollee has requested reimbursement for platelet-rich plasma injections provided from 7/14/17 forward. The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that there is limited reliable clinical evidence to guide the use of platelet-rich plasma injections. Transient side effects, such as post-injection swelling and pain, short duration nausea and dizziness, have been reported in up to 20% of recipients. Side effects appear to be more common with multiple injection protocols. Long-term benefits of platelet-rich plasma have not been demonstrated yet in the knee. Short-term benefits, lasting from six months to over a year, include functional improvement and pain relief. Such effects have been demonstrated primarily in patients under age 50 with mild to moderate osteoarthritis or recalcitrant patella tendinopathy. There is lack of high quality studies regarding platelet-rich plasma injections in the sacroiliac joint or thumb carpometacarpal joints. The effects of platelet-rich plasma on knee osteoarthritis are quite mixed, and the research is not high quality. The majority of published data suggests better symptomatic relief with early osteoarthritis. Kon and colleagues performed a study of platelet-rich plasma injections in patients with early arthritis comparing the effectiveness of platelet-rich plasma with that of both low- and high-molecular-weight hyaluronic acid injections. The authors concluded that platelet-rich plasma is promising for less severe early arthritis for patients under 50 years of age, but not for more severe osteoarthritis, especially in older patients. Filardo and colleagues compared platelet-rich plasma injections to hyaluronic acid injections in a 192 patient randomized controlled trial where three weekly injections were followed for 12 months. Significantly more post-injection swelling and pain was seen in the platelet-rich plasma group, with no significant differences in outcome. The authors concluded that platelet-rich plasma should not be preferred to viscosupplementation. In this case, the patient was treated with platelet-rich plasma injections to his thumb carpometacarpal joints, knees and sacroiliac joint for the presumed diagnosis of osteoarthritis, although the records did not clearly define the indication. The current medical evidence does not support this treatment modality in this setting. The patient is over the age of 50, and the submitted records do not include radiology reports which grade the degree of osteoarthritis, if present. Thus, platelet-rich plasma injections provided from 7/14/17 forward were not and are not likely to be of greater benefit than other treatment alternatives. Based upon the information set forth above, the services at issue were not and are 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 Overturned

Summary Reviewer 1

A 40-year-old female enrollee has requested reimbursement for Anser ADA diagnostic testing performed on 2/18/15. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found that based upon the medical records provided, the Anser ADA assay on 2/18/15 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. This patient was symptomatic with diarrhea and Anser ADA assay was performed to rule out antibodies to Humira, and ensure therapeutic levels of the drug in an attempt to optimize therapy. Therapeutic drug monitoring (TDM) is the clinical practice of measuring drug concentrations or metabolites to attain a targeted concentration in a patient's bloodstream, thereby optimizing individual dosage regimens. Maximizing the efficacy of therapies for inflammatory bowel disease (IBD), while minimizing their toxicity remains the principal objective in developing management strategies for IBD patients. Recognition of the factors influencing therapeutic response allows providers to individualize dosing regimens to meet this objective. In order to optimize IBD therapy, it is critical that prescribers understand that standard dosing is insufficient for most patients, given the interindividual variability relating to response and tolerability. Moreover, the Anser ADA diagnostic test is considered safe and effective in optimizing therapy in patients with Crohns disease that are being treated with anti-tumor necrosis factor (TNF) agents such as Humira. The study by Li and colleagues noted a significant correlation between serum ADA levels and remission in patients with Crohns disease. Therefore, incorporation of Anser ADA diagnostic testing into clinical practice may allow providers to optimize treatment by maintaining effective drug concentrations over time. For the reasons provided, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than other modalities. 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 2


A 40-year-old female enrollee has requested reimbursement for Anser ADA diagnostic testing performed on 2/18/15. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the Anser ADA testing was ordered to determine the etiology for possible loss of response to Humira and to direct the management of the patients Crohns disease. The test revealed a lack of antibodies and that the drug was present. The use of Anser ADA has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. Moreover, the effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with adalimumab may experience loss of response. However, loss of response can be due to multiple factors, and the appropriate method for determination of the cause for loss of response is not clear. Given the lack of supporting demonstrating definitive utility, the ADA diagnostic testing performed on 2/18/15 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 Overturned

Summary Reviewer 3

A 40-year-old female enrollee has requested reimbursement for Anser ADA diagnostic testing performed on 2/18/15. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found that the Anser ADA diagnostic testing performed on 2/18/15 was likely to be more effective for this patient than other available treatment options. There is clinical evidence from observational studies, cohort studies, controlled trials, and meta-analysis in the peer-reviewed medical literature sufficient to support the Anser assay in this clinical setting. In this case, the patient has Crohns disease and has been maintained on adalimumab. However, she developed mild diarrhea with lack of clear endoscopic evidence of recurrence. Hence, while on adequate therapy, ADA diagnostic testing was performed to check for developing adalimumab failure due the development of antibodies, versus subtherapeutic levels versus failure that would necessitate considering alternate therapy. Thus, the indication for the ADA test was the patients Crohns disease and potential developing flare despite being on adequate treatment with adalimumab, as well as ruling out alternate causes complicating her course. For the reasons provided, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, 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 Overturned

Summary Reviewer 


A 52-year-old male enrollee has requested authorization and coverage for Harvoni. 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 due to the approval and availability of new therapies, clinical guidelines and accepted standards of care were completely revised in late 2014. 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, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. These new guideline 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 genotype 1 hepatitis C regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). Additionally, treatment of patients before they progress to F3 or F4 fibrosis is advantageous. Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested Harvoni is medically necessary for treatment of this patients medical condition. Consistent with these findings, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.