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

Summary Reviewer 2

A 54-year-old male enrollee has requested reimbursement for the DecisionDx melanoma assay provided on 2/5/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC)) system that defines cutaneous melanoma stages 0-IV. While the majority of clinical stage I patients will be disease-free at five years, some stage I patients will develop advanced disease. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. DecisionDx melanoma assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class 1 consistent with a low risk of metastasis or Class 2 suggestive of a high risk of metastasis. One peer-reviewed publication indicated that there was a statistically significant association of a Class 1 signature by DecisionDx melanoma assay for primary dermal melanoma (PDM), whereas cutaneous metastatic melanoma (CMM) were more frequently class 2 (Sidiropoulos, et al). The authors concluded that the melanoma prognostic assay may be a useful tool for distinguishing PDM from CMM. According to the results of analysis of this patients melanoma performed with DecisionDx melanoma assay, the tumor was classified as Class 1 with a low risk of near-term (within five years) metastatic disease. Therefore, DecisionDx melanoma signature may be an independent predictor of metastasis risk. However, there is a lack of peer-reviewed published studies confirming this hypothesis. All told, the DecisionDx melanoma assay performed on 2/5/16 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 54-year-old male enrollee has requested reimbursement for the DecisionDx melanoma assay provided on 2/5/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines do not support the DecisionDx testing for use outside of the clinical trial setting. Moreover, there is a lack of peer-reviewed medical literature demonstrating that the results of the DecisionDx testing would change the recommended therapy or long-term outcomes. Consequently, the DecisionDx melanoma assay provided on 2/5/16 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 1

A 50-year-old female enrollee has requested reimbursement for CPT code 81479 (unlisted molecular pathology, Cxbladder) performed on 12/19/18. 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 there is a lack of support for the services at issue in this patients case. Cxbladder testing is not a screening test for urothelial cancer. Cystoscopy and possible biopsy and upper tract imaging will still be necessary regardless of the results of Cxbladder testing. Urinary biomarker tests such as Cxbladder give significant false-negative results in patients with bladder cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors. To date, there are multiple urine markers that have improved sensitivity over cytology, but there is lack of validation of clinical utility. Some of the recently developed markers aim to change the paradigm of urothelial diagnosis and follow-up by replacing or reducing the need of invasive investigations. Further prospective validations are needed to confirm these findings. Therefore, CPT code 81479 (unlisted molecular pathology, Cxbladder) performed on 12/19/18 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 50-year-old female enrollee has requested reimbursement for CPT code 81479 (unlisted molecular pathology, Cxbladder) performed on 12/19/18. 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 bladder cancer molecular testing remains an adjunct to standard evaluation. Standard evaluation includes cystoscopy and urine cytology. Urinary biomarkers, including Cxbladder urine testing, may be useful in increasing the sensitivity of diagnosis. However, urine messenger RNA testing to detect gene expression for bladder cancer cells remains investigational at this time. Superiority of this test compared to conventional evaluation of hematuria remains to be elucidated with further studies. Recommended evaluation continues to be contrast enhanced imaging of the urinary tract and cystoscopy. In sum, CPT code 81479 (unlisted molecular pathology, Cxbladder) performed on 12/19/18 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 50-year-old female enrollee has requested reimbursement for CPT code 81479 (unlisted molecular pathology, Cxbladder) performed on 12/19/18. 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 medical evidence does not support the services at issue in this clinical setting. Cxbladder testing has a beneficial role in the diagnostic work-up of gross or microscopic hematuria when standard evaluation results in equivocal or conflicting information from cystoscopy and imaging studies. In this patients case, the records documented a normal cystoscopy and normal computed tomography (CT) urogram which would not benefit statistically from Cxbladder testing based on the literature and current practice guidelines. Thus, CPT code 81479 (unlisted molecular pathology, Cxbladder) performed on 12/19/18 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 


A 62-year-old female enrollee has requested authorization and coverage for rizatriptan 5 mg, ODT tablets, #12 per month. The Health Insurer has denied this request indicating that the requested medication quantity is not medically necessary for treatment of the enrollees chronic migraines. The physician reviewer found that The medical records provided for review indicates a diagnosis of migraine headache. Peer-reviewed publications have demonstrated that rizatriptan is effective for abortive treatment of migraine headaches. The records from the provider indicate that no other therapy has been effective. With documented diagnosis of migraine and proven effectiveness of the requested quantity, rizatriptan 5 mg, ODT tablets, #12 per month is supported as medically necessary for treatment of this patients migraines. Based on the foregoing discussion, the requested medication quantity is 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 29-year-old female enrollee has requested reimbursement and prospective authorization and coverage for OxyContin 20 mg three times per day from 2/9/18 forward. The Health Insurer has denied this request indicating that the medication dosage at issue was not and is not medically necessary for treatment of the enrollee who has been assessed with chronic pain syndrome. The physician reviewer found that the medical literature states that dose escalation is not a long-term plan but a short-term plan for the treatment of tolerance. In the documentation available for review, there were no objective treatment goals for pain and function noted for the requested medication. In addition, several requirements for opioid prescribing have not been documented to be performed. Therefore, the need to use them as the primary medication treatment strategy for pain has not been established (Chou, et al). The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, providers should prescribe immediate release opioids instead of extended release/long-acting (ER/LA) opioids. When opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, and should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day, and should avoid increasing dosage to 90 or more MME per day or carefully justify a decision to titrate dosage to 90 or more MME per day. In this case, the patient was recently taking 135 MME per day. However, there is no submitted evidence based rationale given by the provider to support the potential long-term consequences with the continual increase in opioids. Risk and benefit analysis must be performed to justify the requested level of 90 MME per day. It is also reasonable to consider alternatives to opioids. Moreover, pure mu agonists are not considered evidence based treatments for fibromyalgia and the adverse effects of opioids in fibromyalgia patients are unknown. In addition, the submitted records do not mention the completion of behavior therapy despite much research to support its use. For all of these reasons, reimbursement and prospective authorization and coverage for OxyContin 20 mg three times per day from 2/9/18 forward has not been demonstrated as medically necessary for treatment of the patients medical condition. Therefore, based on the reasons stated above, the medication dosage at issue was not and is not medically necessary for the treatment of this patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 51-year-old female with chronic left knee pain. The patient has requested authorization and coverage for knee arthroscopy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that this patient has evidence of degenerative changes in the left knee along with meniscocapsular separation, meniscal cyst, and tearing of both menisci. Meniscocapsular separation is a lesion of the attachment of the peripheral section of the meniscus to the capsule and is less common than other meniscus injuries. Per Tiftikci and Serbest, a repair made with the all-inside method is successful clinically and functionally. In addition, it is recommended that the repair is made from the tibial surface, which does not change the anatomic position of the meniscus. A partial medial meniscectomy with removal of the unstable portions of the meniscus is recommended.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The parent of a 10-year-old male enrollee has requested authorization and coverage for Omnitrope (somatropin) injection 1.3 mg/day, six days per week. 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 has no evidence of poor growth on the growth chart. In fact, he went from the 5th to 10th percentile. The diagnosis of growth hormone deficiency without clinical evidence of poor linear growth cannot be supported. Accordingly to guidelines, there is not a single test to diagnose growth hormone deficiency. Although this patient failed the growth hormone stimulation test, in the absence of poor growth, this test alone cannot establish the diagnosis of growth hormone deficiency. This patient was pre-pubertal at 10 years of age. It is likely his growth rate will increase even more when he enters puberty. There is a lack of support for the requested medication in this clinical setting. Therefore, Omnitrope (somatropin) injection 1.3 mg per day, six days per week is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 65-year-old female enrollee has requested reimbursement for inpatient admission from 12/06/17 through 12/07/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the patient presented with anginal type symptoms after a stressor. Although she did not have fixed coronary artery disease, she met all the criteria for Takasubos stress cardiomyopathy with T wave inversions, positive low-level troponin elevations and an echocardiogram, which revealed severe apical hypokinesis with depressed ejection fraction. Although not often associated with fixed coronary artery disease, the prognosis for stress cardiomyopathy is also very guarded, and recent data and meta-analyses reveal that there is significant short and long-term morbidity and mortality associated with this entity.  Therefore, monitoring for rhythm disturbances, hypotension and other complications of myocardial infarction is warranted with an inpatient admission, even if short. Troponins, electrocardiogram and echocardiogram all showed evidence of acute myocardial damage in this patient. Therefore, inpatient admission from 12/06/17 through 12/07/17 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 52-year-old female who presented with a left cheek basal cell cancer. The patient has requested authorization and coverage for brachytherapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that guidelines do endorse the use of brachytherapy in the treatment of skin cancer. Brachytherapy uses a radioactive isotope to deliver therapeutic radiation near or inside the tumor target. In lesions on the face, due to the unique conformality of brachytherapy, there would be less scatter radiation to other nearby facial structures compared to other conventional radiation techniques using external beam radiation therapy. Brachytherapy would allow lower doses to the oral cavity and eye compared to standard techniques. Furthermore, in this case, brachytherapy may be preferentially used to allow for appropriate tumor coverage while allowing for normal tissue sparing. There is sufficient support for the requested services in this clinical setting. Therefore, brachytherapy is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a 16-year-old female enrollee has requested reimbursement for residential treatment center (RTC) services provided from 7/20/16 through 8/24/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees eating disorder. The physician reviewer found that the records provided for review do not support the medical necessity of the RTC services provided from 7/20/16 through 8/24/16 for treatment of this patients medical condition. The patient did not require 24-hour supervision in a highly restricted setting to manage her anorexia and depression safely. According to the America Psychiatric Association (APA), the patients medication management could have been safely and adequately conducted in a less restrictive treatment setting. All told, the RTC services provided from 7/20/16 through 8/24/16 were not medically necessary for treatment of this patients eating disorder. Based on the foregoing discussion, 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 65-year-old female enrollee has requested authorization and coverage for Venclexta (venetoclax) 100 mg, five tablets daily #150. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees multiple myeloma. The physician reviewer found that Venclexta is not considered a standard of care for the treatment of patients with multiple myeloma. In addition, Venclexta is not U.S. Food and Drug Administration (FDA) approved for the treatment of multiple myeloma, supported major drug compenida, or the National Comprehensive Cancer Network (NCCN) guidelines. Venclexta has preliminary data from phase I trials showing it may only be efficacious for patients with certain genetic abnormalities and is the ongoing subject of clinical trials actively recruiting patients. Given the lack of data demonstrating improved patient health outcomes with use of Venclexta, the requested Venclexta (venetoclax) 100 mg, five tablets daily #150, is not supported as 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 requested medication 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 65-year-old female enrollee has requested authorization and coverage for Venclexta (venetoclax) 100 mg, five tablets daily #150. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees multiple myeloma. The physician reviewer found that the use of Venclexta in this clinical setting is currently under investigation for use in combination or as a single agent. Moreau and colleagues study, is a phase Ib study and did not include Dara, hence it does not apply in this case. Phase Ib studies do not prove medical necessity nor do they establish the standard of care. Overall, randomized phase II or III clinical trials establish the standard of care. The response shown in this patient was assumed to be related to Venetoclax while this response could be also related to the other drugs used in this combination. In addition, response by itself is not a surrogate for survival benefit. Review of the patients record indicates that this patient has not been treated with all U.S. Food and Drug Administration (FDA) approved agents for the treatment of multiple myeloma such as Pabobinostat. All told, the requested Venclexta (venetoclax) 100 mg, five tablets daily #150 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, the requested medication 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 65-year-old female enrollee has requested authorization and coverage for Venclexta (venetoclax) 100 mg, five tablets daily #150. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees multiple myeloma. The physician reviewer found that multiple myeloma is a plasma cell neoplasm that extends widely with many systemic complications including anemia, hypercalcemia, bony lytic lesions, and renal failure. Multi-agent chemotherapy is the mainstay of treatment and this is frequently consolidated with autologous hematopoietic stem cell transplant. Overall, it is common for patients to transition from many different agents and lines of therapy. Bortezomib is oftentimes used in newly diagnosed patients and patients with relapsed disease (Kastritis, et al; Reece, et al; Venner, et al). Daratumumab is a monoclonal antibody directed against CD38 that was approved by the U.S. Food and Drug Administration (FDA) for treatment of myeloma in those patients who have progressed on proteasome inhibitor or immunomodulatory agents. A recent phase III, randomized clinical trials showed that daratumumab with bortezomib and dexamethasone had increased overall response rate and improved progression free survival compared with bortezomib and dexamethasone (Palumbo, et al). Given this support, the requested Venclexta (venetoclax) 100 mg, five tablets daily #150 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, the requested medication 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 40-year-old female enrollee has requested authorization and coverage for breast reduction surgery. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee, who reported back, neck and shoulder pain. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. Symptomatic macromastia is a mechanical problem, and conservative treatments have been shown to be ineffective for this condition. Nonoperative treatments are unlikely to improve her pain. This patient has large pendulous breasts with shoulder grooving and the classic symptoms for macromastia. Breast reduction is the only treatment that is proven in the medical literature to be curative for symptomatic macromastia, and the peer-reviewed literature confirms the benefit of breast reduction surgery for women with upper torso pain due to breast hypertrophy. Thus, breast reduction 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.