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

Summary Reviewer 

A 63-year-old female enrollee has requested reimbursement for knee arthroscopy with meniscectomy performed on 9/25/18. 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 this patient presented with progressive right knee pain with associated mechanical symptoms of swelling, catching, and locking. Her pain interfered with activities of daily living and affected her quality of life. Clinical examination findings documented positive McMurrays test consistent with imaging evidence of medial and lateral meniscus tears. There was radiographic evidence of moderate to severe right knee osteoarthritis. She failed to improve despite conservative treatment, including activity modification, medications, physical therapy, and physician directed rehabilitation. She underwent right knee arthroscopy with medial and lateral meniscectomies, synovectomy, and debridement with removal of crystals on 9/25/18. The medical evidence supports the services at issue in this clinical setting. Therefore, knee arthroscopy with meniscectomy performed on 9/25/18 was medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 63-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 hepatitis C. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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 conditions.  Additionally, treatment of patients before they progress to cirrhosis is advantageous.  Based on evidence of safety and efficacy in the published literature, and clinical guidelines, the requested medication Harvoni is medically indicated for the treatment of this patient.  Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 61-year-old male enrollee has requested reimbursement for MRI performed on 5/20/19. The Health Insurer indicated that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient was evaluated with bilateral shoulder MRI. The MRI was grossly positive bilaterally and showed significant internal derangement on both sides. He had severe pain with both internal and external rotation maneuvers on physical examination. While not referred to by name, this phenomenon constitutes a positive Hawkins test and reflects high probability of rotator cuff disease. A positive Hawkins test is a reliable indicator for rotator cuff pathology. In this circumstance, a conservative course of therapy is not required prior to MRI. While a plain film series is usually performed prior to MRI, those films would not have negated the necessity of MRI, since the tendons and joint lining of the shoulders are not visible without MRI. Therefore, MRI performed on 5/20/19 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 60-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/15/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas melanoma. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add a bit to these statistics. DecisionDx-Melanoma testing is a 31-gene assay of molecular pathology in an individualas melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients undergoing sentinel node biopsy. It is not clear how the five-year DecisionDx Melanoma data compares to the ten-year Balch data. Most importantly, it is unknown if it can be used to make clinical therapeutic decisions. This would be particularly true in this patient with an excellent prognosis. Therefore, DecisionDx-Melanoma testing performed on 4/15/19 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 60-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/15/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas melanoma. The physician reviewer found that this patient has an early stage melanoma. Commercially available gene expression profiling (GEP) tests are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear whether these tests provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariable nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and SLNB status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. Newer prognostic molecular techniques should not replace standard staging procedures. There is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. All told, DecisionDx-Melanoma testing performed on 4/15/19 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 60-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/15/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas melanoma. The physician reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. The test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing performed on 4/15/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 61-year-old male enrollee has requested reimbursement for gene expression profiling performed on 5/10/19. 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 patients with superficial bladder cancer are followed with serial cystoscopies and urine cytology. There are a variety of molecular-based markers being studied to improve the results of cytology alone. CxBladder testing has a 93% sensitivity and an 80 to 85% specificity, both of which are better than cytology alone. It is particularly being used in patients whose bladder tumors are deemed to be high risk for recurrence. There is sufficient support for the services at issue in this clinical setting. Therefore, gene expression profiling performed on 5/10/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 61-year-old male enrollee has requested reimbursement for gene expression profiling performed on 5/10/19. 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 supports the services at issue in this clinical setting. The CxBladder test is used to rule out bladder cancer in patients with hematuria as a complement to cystoscopy. Lotan and colleagues performed a study of 803 patients undergoing surveillance for bladder cancer. The authors noted that CxBladder test had superior sensitivity and a negative predictive value compared with cytology, NMP22, and UroVysion. The use of CxBladder can potentially reduce the need for invasive diagnostic testing. All told, gene expression profiling performed on 5/10/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 61-year-old male enrollee has requested reimbursement for gene expression profiling performed on 5/10/19. 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 clinical setting. The patients risk for bladder cancer and prior history are unknown. The test is designed to detect bladder cancer and is a surveillance test that is proposed to be an adjunct to cystoscopy to rule out bladder cancer in patients with increased risk. In this patients case, the stage is unknown. At this time, the CxBladder gene expression test does not appear to be a standard of medical care. Medical evidence does not support its routine use. Thus, gene expression profiling performed on 5/10/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 35-year-old male enrollee has requested reimbursement for rhinoplasty, secondary; major revision (nasal tip work and osteotomies) performed on 11/13/15. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees nasal obstruction. The physician reviewer found that functional rhinoplasty has been demonstrated to improve nasal breathing by addressing structural abnormalities of the nose. However, there was no documentation of preoperative physical examination describing these abnormalities except for the operative note describing valve collapse on the right. Internal valve collapse can lead to nasal obstruction. Placement of precise cartilage grafts have been demonstrated to provide support which improves nasal breathing. This patient had valve collapse, and vestibular stenosis repair should improve his nasal breathing. Therefore, this procedure was medically indicated. However, the osteotomies, cephalic trim and alar reduction were likely cosmetic and not medically necessary. As such, the rhinoplasty was not medically necessary because the osteotomies and tip work were cosmetic in nature. Therefore, the rhinoplasty, secondary; major revision (nasal tip work and osteotomies) performed on 11/13/15 were not medically necessary. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 60-year-old female enrollee has requested authorization and coverage for prescription fenofibric capsules 135 mg, two pills daily.  The Health Insurer has denied this request indicating that the requested medication dosage is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the request medication dosage is not medically necessary for treatment of the patients medical condition. Based on the records provided, the patient presents with hyperlipidemia, intolerance to statin medication due to polyneuropathy, and treatment with fenofibric acid. In this circumstance, the recommended maximum dosage of fenofibric acid is 135 mg once daily, per prescribing information. Higher doses have not been adequately evaluated in the scientific literature. Moreover, the use of fibric acid derivatives is targeted mainly at treatment of high triglycerides and low HDL, neither of which are significantly present on the patients lipid profile while taking the current dose of fenofibric acid 135 mg one tablet daily. Current guidelines on the evaluation and management of dyslipidemia do not recommend fenofibric acid doses more than 135 mg once daily for the treatment of dyslipidemia. Therefore, fenofibric capsules 135 mg, twice daily is not medically necessary for treatment of the patients medical condition. Therefore, the requested medication dosage is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 37-year-old female enrollee has requested authorization and coverage for Gilenya. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees multiple sclerosis. The physician reviewer found that Gilenya is a disease-modifying therapy approved by the U.S. Food and Drug Administration (FDA) for the treatment of multiple sclerosis. One of the major challenges of treating patients with multiple sclerosis is prescribing a regimen that is effective and also regimen with which the patient will comply. Even if a therapy is effective, if a patient does not comply then it is unlikely the therapy will be effective.  In this patients case, Gilenya is a therapy that is effective and one which the patient is compliant as it fits her lifestyle.  There is sufficient support for the requested medication in this clinical setting.  All told, Gilenya is medically indicated for the treatment of this patient.  Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 58-year-old female enrollee has requested authorization and coverage for a left total knee arthroplasty. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the records document chronic left knee pain due to severe osteoarthritis. The arthritis is tricompartmental, with the medial compartment being bone-on-bone. She has severe pain with ambulation and also complains of nocturnal pain interfering with sleep. The provider has documented trial/failure of conservative treatment for several years. On examination, there is a varus deformity. The provider has opined that the patient is a good candidate for outpatient total knee arthroplasty. In reviewing the medical records, the patient does meet the criteria for a successful outpatient total knee arthroplasty. Her age, activity status, degree of pain, nocturnal symptoms, failure of conservative treatment, and radiographic criteria of severe osteoarthritis of the medial compartment and lesser degree of osteoarthritis in the remaining compartments, all meet the guidelines for a successful total knee arthroplasty. The providers request for an outpatient total knee arthroplasty is supported by the medical literature. Therefore, the requested left total knee arthroplasty is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 50-year-old male enrollee has requested reimbursement for the DecisionDx melanoma assay provided on 8/19/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees thin melanoma.   The physician reviewer found that the DecisionDx melanoma assay evaluates the genetics of the melanoma and can stratify whether a thin melanoma is at high risk for metastasis. The DecisionDx test has shown some impressive accuracy in thin melanomas. However, there is a paucity of data showing that the results of this test improve treatment decision making and health outcomes. The treatment of this patient would not change based on the results of the DecisionDx. Moreover, the test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Overall, the test is currently not standard of care, offers no scientific evidence that it has a beneficial effect on health outcomes, and is not recommended by the NCCN guidelines. For these reasons, the DecisionDx melanoma assay provided on 8/19/15 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 Upheld

Summary Reviewer 2

A 50-year-old male enrollee has requested reimbursement for the DecisionDx melanoma assay provided on 8/19/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees thin melanoma.   The physician reviewer found that the DecisionDx melanoma gene testing has been developed to assess risk of melanoma metastasis in the next five years. The National Comprehensive Cancer Network (NCCN) guidelines state that genetic tests such as the DecisionDx, should not be used outside of the clinical trial setting. Consequently, the DecisionDx melanoma assay is not considered within the standard of care. Accordingly, the DecisionDx melanoma assay provided on 8/19/15 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 Upheld

Summary Reviewer 3


A 50-year-old male enrollee has requested reimbursement for the DecisionDx melanoma assay provided on 8/19/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees thin melanoma.   The physician reviewer found that melanoma staging is characterized by the American Joint Committee on Cancer (AJCC). 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 exams and clinical examination. The DecisionDx melanoma gene expression profile (GEP) test is an expression assay designed to predict distant metastasis in stage I and stage II melanoma patients. 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. However, there is a lack of peer-reviewed published studies confirming improved health outcomes with use of this assay over standard testing. Thus, the DecisionDx melanoma assay provided on 8/19/15 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 32-year-old female enrollee has requested reimbursement for targeted genomic sequence analysis panel performed on 7/13/17. The Health Plan has denied this request and reported that the services at issue were not medically necessary for evaluation of the enrollees thyroid nodule.The physician reviewer found that the while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign. The relatively new development of molecular techniques and the identification of genetic alterations associated with different follicular cell-derived cancers in the thyroid have led to the introduction of several commercially available tests. Among the new molecular tests is targeted genomic sequence analysis panel testing. This testing allows simultaneous testing for multiple mutations with high accuracy and sensitivity, requires a small amount of DNA and can be performed in a variety of thyroid tissue and fine-needle aspiration samples, and provides quantitative assessment of mutant alleles. The high sensitivity and specificity of targeted genomic sequence analysis panel helps to identify which neoplasms are more likely to be malignant, while ruling out the benign neoplasms, thereby decreasing the risk of unnecessary surgery. There is sufficient support for the services at issue in this clinical setting. All told, targeted genomic sequence analysis panel performed on 7/13/17 was medically necessary 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.