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

Summary Reviewer 

A 32-year-old male enrollee has requested reimbursement for partial hospitalization services from 1/20/17 through 2/10/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the documentation provided does not support the medical necessity for the services at issue in this clinical setting.  The patient had no withdrawal symptoms. He showed no evidence of being a danger to self or others.  He was cognitively intact and there were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  He was medically and psychiatrically stable. The patient noted that he had not attempted treatment at lower levels of care.  There was no evidence that treatment at a lower level of care would cause relapse or decompensation.  This patient was motivated and engaged in the recovery process.  He had support systems in place. He could have received treatment at a lower level of care. As such, the PHP services for substance use disorders from 1/20/17 through 2/10/17 were not medically necessary for treatment of this patient. Therefore, for the reasons stated above, the services at issue were 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 29-year-old female enrollee has requested reimbursement for the Anser ADA test provided on 10/13/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis.  The physician reviewer found that in this patients case, the Anser ADA test was ordered to determine the etiology for possible loss of response to Humira and to direct management of the patients ulcerative colitis. Overall, the effectiveness of the Anser ADA compared to conventional courses of evaluation remains unproven. Patients being treated with adalimumab may experience loss of response. However, the appropriate method for determination of the cause for loss of response remains uncertain. The available published clinical studies on the use of these serum levels are small and retrospective or observational in nature (Karmiris, et al; Roblin, et al). Prospective controlled trials demonstrating the effectiveness of anti-adalimumab antibody testing and serum level testing as part of the clinical management strategy are lacking. For these reasons, the Anser ADA test provided on 10/13/14 was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 29-year-old female enrollee has requested reimbursement for the Anser ADA test provided on 10/13/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis.  The physician reviewer found that antibodies to adalimumab (ADA) are present in a substantial number of patients treated with adalimumab, and in some patients there may be a correlation between the level of these antibodies and clinical response. However, there are technical factors relating to the use of different assay methods across studies, and it has not yet been established whether the use of threshold level aid in the discrimination of response to adalimumab. There are patients who do not respond to adalimumab (primary non responders), and patients who appear to lose their response to adalimumab over a period of time (secondary non responders). However, some evidence suggests that low serum drug levels and/or the presence of drug antibodies to may play a role in primary or secondary response failures. Menting and colleagues noted that patients with no ADA formation in the first 24 weeks of treatment have little chance of it in the following 24 weeks. The presence of ADA is strongly correlated with adalimumab concentration. Standard alternatives to Anser ADA testing, in patients like this patient, include shortening the interval between doses, increasing the dose, or switching to a different agent. At this time, the peer-reviewed medical literature does not support the use of the Anser ADA test as performed on 10/13/14 as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 29-year-old female enrollee has requested reimbursement for the Anser ADA test provided on 10/13/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis.  The physician reviewer found that monitoring patients on adalimumab with measurement of adalimumab levels and antibodies continues to be an area of intense investigation. In general, adalimumab levels correlate inversely with disease activity. However, the target level of adalimumab necessary to achieve clinical benefit remains unknown. There is a lack of controlled data which have identified the optimal drug level and the issue remains speculative. Although appealing this algorithmic approach has not been validated using prospectively controlled data. Consistent with these findings, the Anser ADA test provided on 10/13/14 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, I have determined 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 61-year-old female has requested authorization and coverage for 64568, 0466T and 95970. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea.  The physician reviewer found that this patient has requested implantation of hypoglossal nerve stimulation for her symptoms of obstructive sleep apnea. She previously was treated with CPAP therapy, but the patient became intolerant to the use of this device. Sleep study reports documented increasing symptoms of obstructive sleep apnea with apnea-hypopnea index at the moderate level of obstructive sleep apnea syndrome. Hypoglossal nerve stimulation therapy has been proven by the U.S. Food and Drug Administration (FDA) to be an effective modality of treatment of obstructive sleep apnea in patients with tongue-based obstruction. This patient did have evidence of some degree of tongue base obstruction based on sleep endoscopy procedure. Although this patient meets some of the criteria for implantation of upper airway stimulation, she has not undergone other methods of management.  Other surgical procedures have not been attempted, such as nasal turbinate reduction and/or nasal septal reconstruction.  These methods have been shown to improve tolerance to nasal CPAP therapy. Additionally, the patient may be a candidate for other traditional oropharyngeal surgery, such as uvulopalatopharyngoplasty with tonsillectomy, which may improve symptoms. Therefore, the requested services (64568, 0466T and 95970) are not likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested services 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 61-year-old female has requested authorization and coverage for 64568, 0466T and 95970. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea.  The physician reviewer found that this patient has severe obstructive sleep apnea and has not been able to tolerate the CPAP device. She has septal deviation. She had a sleep endoscopy which showed anteroposterior collapse and minimal lateral collapse. The Inspire device has been approved by the U.S. Food and Drug Administration for the treatment of obstructive sleep apnea. However, the patient has septal deviation which has not been treated surgically, and this can improve her ability to tolerate the CPAP device. At this point, she is not a candidate for the Inspire device. There is a lack of support for the requested services in this clinical setting. Thus, the requested services (64568, 0466T and 95970) are not likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested services 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 61-year-old female has requested authorization and coverage for 64568, 0466T and 95970. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea.  The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. She has obstructive sleep apnea. The records noted prior use of CPAP. However, the records do not document attempts at helping the patient with tolerating the CPAP were exhausted. The clinical notes do not document that conservative treatment options have been exhausted, including oral appliance therapy. All told, the requested services (64568, 0466T and 95970) are not likely to be more effective than other treatment alternatives. Based upon the information set forth above, the requested services 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a 17-year-old male enrollee has requested authorization and coverage for Nutropin. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees short stature. The physician reviewer found that the records provided for review document that this patient has been receiving GH therapy for GH deficiency. Based on current guidelines from the Lawson Wilkins Pediatric Endocrinology Society Drug and Therapeutics Committee and American Association of Clinical Endocrinologists, continuation of therapy is medically necessary until epiphyseal fusion and/or until growth velocity is less than 2 cm per year. Based on the report from the most recent examination by the patients provider in January 2016, the patient still has open epiphyses and continues to grow at a growth rate that is greater than 2 cm per year. Thus, the requested GH therapy with Nutropin is medically necessary for this patient. Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 34-year-old female enrollee has requested reimbursement for genetic testing for birth defects performed on 3/28/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found screening for aneuploidy via cfDNA screening has been shown to be an appropriate methodology for high-risk women, as established by current American Congress of Obstetricians and Gynecologists (ACOG) guidelines. Per guidelines, high-risk conditions include age at or over 35 at time of delivery or a history of a prior pregnancy affected with one of the aneuploidies screened for by this test. Based on the clinical documentation submitted for review, the patient is not a high-risk patient warranting cfDNA screening. In sum, the genetic testing for birth defects performed on 3/28/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.ased upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


A 34-year-old female enrollee has requested reimbursement for genetic testing for birth defects performed on 3/28/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the American College of Obstetricians and Gynecologists recommends cell free fetal DNA to be utilized as a primary screening test in women at increased risk of aneuploidy. This includes women aged 35 years or older, women with a positive first-trimester or second-trimester screening test result, fetuses with ultrasonographic findings that indicate an increased risk of aneuploidy, women with a history of a child affected with a trisomy, or a parent carrying a balanced Robertsonian translocation with increased risk of trisomy 13 or trisomy 21. In this case, the patient does not meet any of these criteria, thus the testing was not indicated. Therefore, the testing at issue 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 34-year-old female enrollee has requested reimbursement for genetic testing for birth defects performed on 3/28/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the American College of Obstetrics and Gynecology (ACOG) addressed the issue of the use of cell free DNA testing stating given the performance of conventional screening methods, the limitations of cell free DNA screening performance, and the limited data on cost effectiveness in the low risk obstetrical population, conventional screening methods remain the most appropriate choice for first-line screening for most women in the general obstetric population. Given the lack of support by national guidelines, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapies.Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 22-year-old female enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 1/16/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the submitted records fail to demonstrate the superior efficacy of the services at issue.  Some evidence exists that low serum levels of adalimumab and/or the presence of antibodies to adalimumab may play a role in primary or secondary response failures.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment.  The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of adalimumab or the presence of adalimumab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  However, while there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  In addition, there are technical factors relating to the use of different assay methods across studies.  It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  All told, Anser ADA testing performed on 1/16/15 was not likely to have been of greater benefit than other available 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.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 22-year-old female enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 1/16/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the use of Anser ADA has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility.  In this case, Anser ADA was ordered to determine the etiology for possible loss of response and reaction to Humira, and to direct the management of the patients Crohns disease.  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.  The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature.  These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking.  Therefore, Anser ADA testing performed on 1/16/15 was not likely to have been superior over other modalities for 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.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 22-year-old female enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 1/16/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found this patient has Crohns disease, for which she had a colectomy and has been maintained on Humira.  However, she had ulcerations in the terminal ileum which would be concerning for active disease on Humira.  The testing at issue evaluates for adalimumab blood level and for antibodies to adalimumab.  Due to the multitude of management options once a patient has no response to Humira and the fact that Humira has a wide array of adverse effects, it is important for the treating provider to have a roadmap of the nature of the patients clinical course.  Thus, Anser ADA testing performed on 1/16/15 was likely to be of greater benefit than other alternatives.  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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 63-year-old male with a history of oligometastatic castration sensitive prostate cancer, with disease extension to a pelvic lymph node, L1, and left ischium. The physician reviewer found that IMRT is standard of care and medically necessary in this clinical setting. Parker and colleagues discussed radiation therapy to the prostate and noted, aOverall survival did improve in men with a low metastatic burden. Therefore, prostate radiotherapy should be a standard treatment option for men with a low metastatic burden.a IMRT is frequently utilized for similar patients in the radiation oncology community. IMRT allows for optimal target coverage while minimizing exposure to the patientas bowel and bladder. The medical evidence supports the requested services in this patientas case. Therefore, the requested radiation therapy (IMRT) is medically necessary for the treatment of this patient.