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

Summary Reviewer 2


The parent of a four-year-old male enrollee has requested reimbursement for FirstStepDx Plus dated 5/12/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees autism spectrum disorder. The physician reviewer found that chromosomal microarray (CMA) and Fragile X testing are recommended by the American College of Medical Genetics (ACMG) as a first-tier tests for patients with ASD. The yield of CMA in patients with ASD is estimated to be around 10%. CMA has become the standard of care for diagnosis in patients with ASD. Increasing numbers of patients with ASD have been found to have underlying copy number variations. As such, it is possible that some copy number variations have also been associated with specific neuropsychological treatments or medications that have been shown to be more efficacious in patients with ASD due to that underlying cause. Additionally, copy number variations on CMA may inform about possible other complications and medical risks, some of which can be screened for and treated. Fragile X is one of the most common causes of ASD in males. As many as 6% of males with ASD have been found to have Fragile X. Identification of Fragile X will have increasing importance as growing numbers of clinical trials for therapeutic agents begin for Fragile X. All told, the FirstStepDx Plus performed on 5/12/16 was 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 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


The parent of a four-year-old male enrollee has requested reimbursement for FirstStepDx Plus dated 5/12/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees autism spectrum disorder. The physician reviewer found the clinical utility of CMA and Fragile X testing is well established in the medical literature. Both CMA and Fragile X are considered first-line tests for patients with developmental delays and autism spectrum disorders according to the American College of Medical Genetics (Schaefer, et al). These tests provide both a unifying diagnosis, as well as clinically actionable information. Coulter and colleagues performed a study of patients with developmental delay, intellectual disability, autism spectrum disorders and congenital anomalies in order to determine the proportion of cases where abnormal CMA results impacted recommendations for clinical action. Among the 1,792 patients reviewed, 13.1% had clinically relevant results, either abnormal 7.3% or variants of possible significance (VPS) 5.8%. When an abnormal result was identified, a recommendation for clinical action was made 54% of the time and 34% of the time for VPS. Findings in this study demonstrated that CMA results influenced medical care in the majority of patients by precipitating medical referrals, diagnostic imaging, or specific laboratory testing supporting the use of CMA as a clinically useful diagnostic test. Recognition of Fragile X, much like copy number variants in CMA testing is clinically relevant for several reasons. This diagnosis allows for the routine evaluation of seizures, heart problems and vision problems.  It is also important to note that a diagnosis of Fragile X syndrome allows families to better understand recurrence risk in future pregnancies. For the reasons provided, the FirstStepDx Plus performed on 5/12/16 was 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 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 62-year-old male enrollee has requested reimbursement for the Life Vest provided on 1/20/14. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees paroxysmal atrial flutter and atrial fibrillation with rapid ventricular response.   The physician reviewer found that based on the records provided, the patient has newly recognized severely depressed LV ejection fraction due to a non-ischemic cardiomyopathy possibly tachycardia mediated. In this circumstance, there is potential for recovery of LV function with medical therapy and atrial flutter ablation. Thus, there was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until at least 90 days have elapsed with continued LV dysfunction with an ejection fraction 35% or less is documented to persist in spite of appropriate treatment (Russo, et al).  A prophylactic defibrillator (wearable or implantable) before this time has passed has not been demonstrated to improve outcome (Hohnloser, et al). At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. For these reasons, the use of the Life Vest provided on 1/20/14 was 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, I have determined the device at issue was 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 reimbursement for the Life Vest provided on 1/20/14. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees paroxysmal atrial flutter and atrial fibrillation with rapid ventricular response.   The physician reviewer found that the Life Vest wearable defibrillator is a U.S. Food and Drug Administration (FDA) approved device for prevention of sudden cardiac death for patients at increased risk for life threatening arrhythmias, ventricular tachycardia and ventricular fibrillation. However, the efficacy of the Life Vest for specific groups of patients is still being determined. For patients with acute heart failure, such as the patient in this case, the usefulness of the device is still being evaluated (Klein, et al). Zishiri and colleagues reported data that support the use of the Life Vest wearable defibrillator in the post-myocardial infarction phase, or immediately post-revascularization after myocardial infarction, which is not the case for this patient. Moreover, this patient does not meet current indications for an implantable cardioverter defibrillator, which may support an indication for the Life Vest. He has a newly diagnosed non-ischemic cardiomyopathy, possibly tachycardia-induced, due to rapidly conducted atrial flutter. All told, the current peer-reviewed medical literature does not indicate the Life Vest provided to this patient on 1/20/14 was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the device at issue was 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 62-year-old male enrollee has requested reimbursement for the Life Vest provided on 1/20/14. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees paroxysmal atrial flutter and atrial fibrillation with rapid ventricular response.   The physician reviewer found that an increase in the risk of sudden cardiac death, and a potential benefit from implantable cardioverter defibrillator (ICD) implantation, has long been recognized in patients with LV dysfunction related to underlying ischemic heart disease. An increase in sudden cardiac death risk and potential benefit from an ICD has also been demonstrated in patients with a non-ischemic cardiomyopathy (Chung, et al; Epstein, et al). The Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE) trial compared ICD implantation with standard medical therapy to standard medical therapy alone for primary prevention of sudden cardiac death in patients with a non-ischemic cardiomyopathy, non-sustained ventricular tachycardia, and LV ejection fraction of 35% of less. The authors reported findings toward mortality benefit in patients who received an ICD, regardless of duration since diagnosis. This patient was found to have a LV ejection fraction of less than 35%. Thus, the use of the Life Vest provided on 1/20/14 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the device at issue was 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 1

A 59-year-old female enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan performed on 2/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees rigidity, lack of response to Sinemet trial, with suspected Parkinsons disease. The physician reviewer found that in the medical literature, Suwijn and colleagues reported that Parkinsons disease (PD) is wrongly diagnosed in 6 to 25% of cases. To improve the accuracy of the clinical diagnosis, it is necessary to have a reliable and practical reference standard. Dopamine transporter single-photon emission computed tomography (DAT SPECT) imaging might have the potential (high diagnostic accuracy and practical to use) to act as reference standard in detecting nigrostriatal cell loss in patients with (early stage) parkinsonism. Kagi and colleagues found that the use of DAT SPECT can prove or exclude with high sensitivity nigrostriatal dysfunction in those cases and facilitates early and accurate diagnosis. Thus, the literature does support the use of DAT SPECT for the diagnosis of Parkinsons disease. Given this support, the SPECT scan performed on 2/17/15 was 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 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 59-year-old female enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan performed on 2/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees rigidity, lack of response to Sinemet trial, with suspected Parkinsons disease. The physician reviewer found that in one study investigating the negative predictive value of imaging in questioned Parkinsons disease, Marek and colleagues found that in non-DAT avid patients, the likelihood of progressing on to Parkinsons disease is negligible (Marek, et al). This indicates a reasonable test to exclude Parkinsons disease in the presence of questionable symptomatology. In a large cohort from Ravina and colleagues, the authors noted a diagnostic and predictive benefit to early baseline DAT SPECT imaging in the outcomes of patients followed. Subsequent scans were less effective in guiding management, but initial baseline imaging was found predictive. In the case presented, an initial baseline DAT SPECT scan to establish the diagnosis in initial therapy resistant weakness and tremor is both efficient and prudent in establishing therapy and helping to curtail future debilitation. Given these findings, the SPECT scan performed on 2/17/15 was 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 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 59-year-old female enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan performed on 2/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees rigidity, lack of response to Sinemet trial, with suspected Parkinsons disease. The physician reviewer found that in the current medical literature, DAT SPECT imaging of the brain has been shown to be helpful in the diagnosis of suspected Parkinsons disease. The agent used is a specific isotope which localizes areas of differential function (Djang, et al). In this patients case, the use of the DAT SPECT scan assisted in the diagnosis of Parkinsons disease, which in turn prompted treatment. All told, the peer-reviewed medical literature supports the clinical utility of the SPECT scan at issue as useful and likely to be more beneficial in evaluating and treating this patient than any available modality. Based upon the information set forth above, I have determined 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 parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for inpatient rehabilitation treatment provided from 8/27/15 through 9/25/15.  The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees severe scleroderma. The physician reviewer found the submitted documentation establishes the medical necessity of the services at issue. This patient presents with scleroderma leading to flexion contractures of his extremities, with resultant decrease in ability to perform activities of daily living and maintain normal function. The difficult part of treating these contractures is that he has significant skin fragility due to the scleroderma. He has progressed in inpatient therapy, but it is felt that he needs more time to reach his goals. In this clinical setting, it is medically necessary for the patient to remain in inpatient rehabilitation due to the issue of the skin fragility. He is getting assessments multiple times a day for skin breakdown, and coordinated care between therapists, nursing staff, and physicians to ensure that his skin is dry and intact. He is currently receiving constant adjustments in his splinting and casting to ensure maximum benefit without breakdown of the skin. The risk of not treating this patient in an inpatient setting is worsening of hand function and skin breakdown leading to infection or chronic pain. As such, inpatient rehabilitation treatment provided from 8/27/15 through 9/25/15 was and is medically necessary for treatment of this patients medical condition. For the reasons provided, the services at issue were and are 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 

The patient is a 33-year-old female who presented to her provider on 1/22/18. The records noted a body mass index of 41.1 kg/m2, consistent with obesity, and comorbidities including snoring/possible sleep apnea, and musculoskeletal pain. The physician reviewer found that the submitted records fail to demonstrate the medical necessity of the requested services. No gastrointestinal symptoms are reported. The most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines for appropriate use of endoscopy recommend endoscopy for investigation of upper gastrointestinal symptoms when those symptoms are refractory to proton pump inhibitor taken properly for four to eight weeks without response, or for specific indications such as dysphagia. In this case, the provided information does not clearly document any such symptoms, or if symptoms were present, an attempt at treatment. The provider has not reported how management will change (i.e. surgery would be cancelled) based on findings. Endoscopy in asymptomatic patients before bariatric surgery has not been established as standard. Large studies have supported pre-surgery endoscopy only in symptomatic patients. For these reasons, esophagogastroduodenoscopy is not supported as medically necessary for the evaluation of this patients pre-bariatric surgery status in this case. Therefore, flexible esophagogastroduodenoscopy with biopsy performed on 3/03/18 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 38-year-old female with a history of hidradenitis suppurativa (HS). The patient has requested authorization and coverage for Otezla. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that Hidradenitis suppurativa (HS) is a chronic disease that can impact an individualas quality of life.  Humira is the only U.S. Food and Drug Administration (FDA) approved immunosuppressant for the treatment of HS. It is indicated for moderate to severe HS. Per the medical evidence, other biologic treatment options include infliximab, anakinra, and ustekinumab. However, as noted by Alikhan and colleagues, with these medications, aplacebo-controlled dose-ranging studies are needed to determine the optimal dosage for management.a Since these are biologics as well, they also decrease the immune system like Humira. Otezla has a different mechanism of action.  In the randomized controlled trial by Vosen and colleagues, Otezla was shown to be effective in treating moderate HS. The main side effects of this medication is gastrointestinal side effects.  In this case, the patient has maximized her medical and surgical options. She is on weekly dosing of Humira and still has breakthrough symptoms in the groin. At this point, another adjunctive treatment is recommended. Based on the records, a trial of Otezla is medically indicated. Therefore, Otezla is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


The parent of a five-year-old male enrollee has requested reimbursement for the comparative genomic hybridization (CGH) FirstStep DX Plus testing performed on 10/15/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that according to Slavotinek, Array comparative genomic hybridization (array CGH) has revolutionized the cytogenetic testing available for patients with learning disabilities who have chromosomal phenotypes with dysmorphic features and multiple anomalies. Screening large patient cohorts with mental retardation by array CGH has recently lead to the characterization of many novel microdeletion and microduplication syndromes, initially according to the shared cytogenetic aberrations, with secondary characterization of the corresponding phenotypes. The author further states that, it is clear that array CGH has heralded an unparalleled era of discovery for clinical cytogenetics. Data have now emerged showing that actionable findings from chromosomal microarray justify its use. Given the support in the peer-reviewed literature, the comparative genomic hybridization (CGH) FirstStep DX Plus testing performed on 10/15/15 has been established 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, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


The parent of a five-year-old male enrollee has requested reimbursement for the comparative genomic hybridization (CGH) FirstStep DX Plus testing performed on 10/15/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that FirstStep DX Plus testing performed on 10/15/15 was likely to be more effective for this patient with autism than other available treatment options. The study by Henderson and colleagues retrospectively reviewed the medical records of patients who had abnormal chromosomal microarray findings reported per laboratory over a three-year period and quantified the management recommendations made in response to these results. The authors concluded that, These results empirically demonstrate the clinical utility of chromosomal microarray by providing evidence that management was directly affected for the majority of patients in our cohort with abnormal chromosomal microarray findings. Based on the support in the medical literature, the comparative genomic hybridization (CGH) FirstStep DX Plus testing performed on 10/15/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.