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

Summary Reviewer 3


A 45-year-old female enrollee has requested reimbursement for FoundationOne gene testing performed on 3/26/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees adenosarcoma of the cervix.        The physician reviewer found this patient has a rare uterine sarcoma that has not been extensively studied. A study of 86 patients where the progression-free survival on regimen selected by molecular profiling was compared to progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage (Von Hoff, et al). This trial has very significant results for patients with stage IV tumors.  The results from molecular profiling offer a rational selection of the next regimen. This patient has a rare form of cancer and she has exhausted conventional therapies for treatment.  Thus, the submission of her tissue for analysis to FoundationOne, in an effort to guide next steps in her treatment, was likely more beneficial than conventional therapies. 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 


A 59-year-old female enrollee has requested authorization and coverage for Viekira Pak. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus (HCV). The physician reviewer found that review of the submitted documentation establishes the medical necessity of the requested medication. According to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for HCV treatment Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. AASLD/IDSA guidelines further adding that The goal of treatment of HCV-infected persons is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. Additionally, the study by Ferenci and colleagues concluded that Twelve weeks of treatment with ABT-450/r-ombitasvir and dasabuvir without ribavirin was associated with high rates of sustained virologic response among previously untreated patients with HCV genotype 1 infection. Rates of virologic failure were higher without ribavirin than with ribavirin among patients with genotype 1a infection but not among those with genotype 1b infection. Therefore, based upon the peer reviewed literature cited above, 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 48-year-old male enrollee has requested authorization and coverage for cervical artificial discectomy and second level cervical discectomy.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that the requested services are not likely to be more effective for this patient than other available options. Based on the documentation submitted for review, the patient has ill- defined neck pain and upper extremity symptoms. There is a lack of evidence demonstrating cervical radiculopathy (Bono) with dermatomal and myotomal symptoms and findings matching that diagnosis with correlation of radiographic findings. In addition, his pain generator has not been defined. There is a lack of conclusive evidence, including physical findings to implicate the C5-6 or the C6-7 level as the patients source of pain. Although the study by Davis and colleagues is encouraging, there is a lack of support in the peer-reviewed literature demonstrating the long term safety and effectiveness of Mobi-C. All told, the requested surgery 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 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 48-year-old male enrollee has requested authorization and coverage for cervical artificial discectomy and second level cervical discectomy.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found thatthe requested cervical artificial discectomy and second level cervical discectomy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Two level total disc arthroplasty has become accepted by the neurological community to be superior to a two level anterior cervical discectomy and fusion (ACDF) especially in younger patients, such as in this case. There is a growing body of evidence in the peer-reviewed literature that demonstrates two level total disc replacement is associated with a lesser incidence of adjacent level disease than a two level anterior cervical fusion.  Given, the above, the requested services are 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 services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 48-year-old male enrollee has requested authorization and coverage for cervical artificial discectomy and second level cervical discectomy.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that there is insufficient data to adequately assess the performance of total disc replacement. There is a lack of evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. Total disc replacement has been associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been fully documented. The standard procedure in this clinical setting is a two level anterior cervical discectomy and fusion. The proposed surgery has not been established 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 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 1


A 62-year-old male enrollee has requested authorization and coverage for sacroiliac joint (SI) fusion/percutaneous spine fusion. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees SI joint disorder. The physician reviewer found that A review of current peer-reviewed literature and evidence based medical guidelines demonstrates a lack of strong evidence supporting the efficacy of sacroiliac joint fusion in this patients case. Shaffrey and Smith concluded that there was insufficient high-quality evidence regarding surgical management of SI joint pathology to support the role of SI joint fusion in the management of chronic lower back pain.  Zaidi and colleagues found that surgical intervention for SI joint pain was beneficial in a subset of patients but evidence for the efficacy of SI joint fusion was lacking. They recommended that serious consideration of the cause of pain and alternative treatments should be given before performing an SI joint fusion. For these reasons, the requested procedure 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 procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


A 62-year-old male enrollee has requested authorization and coverage for sacroiliac joint (SI) fusion/percutaneous spine fusion. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees SI joint disorder. The physician reviewer found that the selected procedure is a minimally invasive surgery which is more likely to be of benefit than any standard therapy for treatment of this patients SI dysfunction. The current medical literature pertaining to sacroiliac joint fusion demonstrates that surgical intervention for sacroiliac joint pain is beneficial in a subset of patients. Ledonio and colleagues studied 63 patients who underwent sacroiliac joint fusion with minimum one year follow-up. All patients had sacroiliac joint dysfunction confirmed by image guided intra-articular anesthetic sacroiliac joint injection and had failed non-operative treatment. The estimated blood loss, surgery time and length of stay favored the minimally invasive surgery sacroiliac fusion group. An article by Zaidi and colleagues demonstrates rates of excellent satisfaction determined by pain reduction, function, and quality of life ranged from 18%-100% with a mean of 54% in the open surgical cases and 56-100% with a mean of 84% in the minimally invasive surgery patients. The conclusion was that surgical intervention for sacroiliac joint pain was beneficial in a subset of patients. Although long-term results are still lacking, at this time there is sufficient data demonstrating that the requested sacroiliac joint fusion is likely to be more beneficial for treatment of the patients SI joint dysfunction than available standard modalities. In sum, the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 62-year-old male enrollee has requested authorization and coverage for sacroiliac joint (SI) fusion/percutaneous spine fusion. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees SI joint disorder. The physician reviewer found that the submitted documentation fails to demonstrate the efficacy of the sacroiliac fusion, over any standard therapy. The case specific reasons reference a documented clinical syndrome of complex regional pain syndrome with multiple pain generators contributing to the patient's experience of chronic pain. The patient has had an L4-S1 fusion and has had procedures above the levels of fusion but those procedures do not rule out the likelihood of continuing chronic pain from adjacent segment disorder above the levels of fusion. The issue of pain originating at the sacroiliac joint remains controversial, both in general and in patients such as this patient. In the study by Rupert and colleagues, it is pointed out that there are no definitive historical, physical or radiological features that can definitely establish a diagnosis of sacroiliac joint pain. In this specific patient, local anesthetic injection sometimes used in an effort to localize the sacroiliac joint as a pain generator gave only a short-term relief of symptoms. The reliance of local anesthetic injection in the sacroiliac joint to establish that joint as the prime pain generator is susceptible to placebo effect. The statement of a positive benefit from local steroid injection to the sacroiliac joint is not sufficient to provide evidence for likely benefit through the proposed sacroiliac fusion. In summary, it is not likely to be beneficial for this patient to undergo sacroiliac fusion for treatment of his chronic pain.  For the reasons set forth above, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 59-year-old male enrollee has requested reimbursement for positron emission tomography/computed tomography (PET/CT) scan and magnetic resonance imaging (MRI) of the pelvis performed on 6/03/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found this patient had appropriate but incomplete surgical treatment for his prostate cancer.  Per the medical records, C-11 choline PET scan and MRI of the pelvis including a transrectal coil discovered the residual tumor, allowing for appropriate treatment.  There is sufficient support for C-11 choline PET scans to search for biochemical cases of recurrence when conventional imaging has proven to be negative.  Additionally, the use of MRI of the pelvis when prostate recurrence is suspected is commonplace and indicated particularly with endorectal coil in order to visualize the prostatic bed and adjacent lymph nodes.  Also, this exam can be compared with the results of the C-11 choline PET scan.  The combination of the two offers the best detail of the prostatic bed and surrounding lymph nodes, which is crucial in a patient with a history of biochemical prostate cancer recurrence without obvious cause on conventional imaging.  Since conventional imaging has been suboptimal for this patient in the past, the PET/CT scan and MRI of the pelvis performed on 6/03/15 were medically indicated for the evaluation of this patient.  Therefore, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 61-year-old female enrollee has requested reimbursement for the office visits provided on 5/20/16, 8/25/16, and 11/17/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees hypothyroidism, Hashimotos thyroiditis, menopause syndrome, and iron deficiency anemia. The physician reviewer found that the records document that the office visit on 5/20/16 was indicated to follow the patients thyroid levels. However, there is a lack of evidence supporting follow-up office visits on 8/25/16 and 11/17/16. Although it is important to follow thyroid stimulating hormone (TSH) and free T4 in patients on LT4 and T3, it is unclear why these need to be checked every three months for this patient. Given these findings, the office visit on 5/20/16 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, while the office visits on 8/25/16 and 11/17/16 were 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, a portion of 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 partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 61-year-old female enrollee has requested reimbursement for the office visits provided on 5/20/16, 8/25/16, and 11/17/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees hypothyroidism, Hashimotos thyroiditis, menopause syndrome, and iron deficiency anemia. The physician reviewer found that Hypothyroidism, also called underactive thyroid or low thyroid, is a common disorder of the endocrine system in which the thyroid gland does not produce enough thyroid hormone. If not properly treated, hypothyroidism can cause a number of symptoms such as poor ability to tolerate cold, a feeling of fatigue, constipation, depression, and weight gain. LT4 monotherapy has emerged as the therapy of choice for treatment of hypothyroidism (Hennessey). However, due to the narrow therapeutic window of LT4, it is important to closely monitor dose selection and achievement of thyrotropin goals that are specific to the individual patients overall clinical situation (Jonklaas). Providers should follow patients closely in order to properly adjust their dosages of thyroid hormone therapy. For these reasons, the office visits provided on 5/20/16, 8/25/16, and 11/17/16 were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 61-year-old female enrollee has requested reimbursement for the office visits provided on 5/20/16, 8/25/16, and 11/17/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees hypothyroidism, Hashimotos thyroiditis, menopause syndrome, and iron deficiency anemia. The physician reviewer found that meta-analysis of randomized clinical trials shows no advantage of T4 and T3 combination therapy over T4 monotherapy (Grozinsky-Glasberg, et al). This patients records do not include documentation of trial and failure or contraindication to the available formulary alternatives for management of hypothyroidism (Jonklaas, et al). Due to lack of clinical documentation, detailed physical examination findings, history of present illness, and clinical documentation to support an indication of specialty services, the office visits provided on 5/20/16, 8/25/16, and 11/17/16 were not likely to be more beneficial for evaluation of the patients medical condition than any available standard services. 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 Overturned

Summary Reviewer 

The patient is a 38-year-old female with a history of hidradenitis suppurativa that has not responded adequately to multiple therapies, including topical and oral clindamycin, doxycycline, rifampin, cortisone injections, spironolactone, vitamin D and Humira. In a letter dated 11/30/20, the patientas provider reported that the patient was started on Otezla in combination with her Humira treatment in October of 2020 and has responded very well. The physician reviewer found that there is support for the requested medication in this clinical setting. Adalimumab (Humira) is the only U.S. Food and Drug Administration (FDA) approved therapy for hidradenitis suppurativa (HS), which the patient is currently taking. She has a failed a number of other commonly used drugs, many of which are listed in the North American HS treatment guidelines. Of note, apremilast (Otezla) is not listed within these guidelines published in 2019. However, there was one very small randomized controlled trial and also an open-label observational study evaluating Otezla as a treatment for HS, which both showed modest efficacy after 16-24 weeks of therapy. Given the modest benefit reported for Otezla in the literature, it would be medically reasonable to
continue this treatment for another two months to determine if there is any clinical benefit from the drug and reassess the need thereafter. Therefore, Otezla is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 46-year-old male enrollee has requested reimbursement and prospective authorization and coverage for Januvia. The Health Insurer has denied this request indicating that the medication at issue was not and is not medically necessary for treatment of the enrollees diabetes.  The physician reviewer found that Diabetes is a progressive disease, which typically manifests with increasing loss of glycemic control over time in spite of lifestyle and pharmacologic intervention. Although type 2 diabetes is initially due to insulin resistance, studies have shown that patients with this disease also may have a decline in pancreatic beta cell function, which begins as early as 12 years before diagnosis and continues throughout the disease process (Fonseca). New diabetic medications have been developed which are being used earlier in the course of treatment of diabetes. Among these is the DPP4 inhibitors (DPP4i), such as Januvia, which are a class of newly developed antidiabetic drugs which help lower blood glucose levels and may help preserve pancreatic beta cell function (Godinho, et al). In addition, the 2015 comprehensive management algorithm published by the American Association of Clinical Endocrinologists (AACE) recommends that this medication may be used as either monotherapy or in combination therapy for treatment of diabetes (Garber, et al). While this patient responded well to combination therapy of Januvia and metformin, his glycemic control worsened after switching to another medical regimen. Improper management of diabetes could increase a patients risk of developing complications from diabetes and possibly lead to a more rapid progression of diabetes. Consistent with these findings, treatment with Januvia was and is medically necessary for treatment of this patients diabetes. Based on the foregoing discussion, the medication at issue was and is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.