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

Summary Reviewer 3

A 56-year-old female enrollee has requested reimbursement for a blood test performed on 11/24/18. 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 American College of Gastroenterology guidelines for dyspepsia support the use of Helicobacter pylori testing for evaluation of symptoms. The current medical literature supports the use of Helicobacter pylori testing to check for this infection as a cause for pain. Although alternative tests are available, a negative antibody test can rule out Helicobacter pylori infection as a cause for symptoms. In this case, in which the patient reported prior infection, the Helicobacter pylori antibody test can rapidly eliminate Helicobacter pylori infection as a cause for symptoms if negative, and establish the need for additional testing if positive. For these reasons, the blood test performed on 11/24/18 was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 51-year-old male with a history of chronic right knee pain due to advanced tricompartmental osteoarthritis.The patient has requested authorization and coverage for total knee arthroplasty. 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 the patient has a history of chronic tricompartmental osteoarthritis of the right knee for which a total knee arthroplasty is requested. The disputed issue pertains to the BMI of 36.26 according to the medical records, which necessitates documentation of a weight loss plan according to the Health Insurer. The patient states that his BMI is 32.3. A review of the medical records indicates that the patient is a body builder and a fitness enthusiast who has tried other options and is likely to do well after this surgery. Although obesity is associated with a higher cardiovascular risk, every patient should be evaluated on an individual basis and it should not be an absolute contraindication. In this case, with the history of physical fitness, and the motivation of the patient, the higher BMI in itself is not a contraindication to total knee arthroplasty. Considering the individual circumstances, a good result should be expected from the surgery. There is sufficient support for the requested services in this clinical setting. Therefore, the requested total knee arthroplasty is medically necessary for the treatment of this patient
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 54-year-old male enrollee has requested reimbursement for DecisionDx melanoma test performed on 11/9/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee who presented with a mole on his left upper back.   The physician reviewer found that the records indicated that this patient does not have melanoma, hence ordering the melanoma decision DecisionDx melanoma test was not indicated. The diagnostic test DecisionDx melanoma test is considered experimental. The test claims to determine risk of recurrence for early melanoma in patients with stage I or II. There is a lack of data to support using immunotherapy in the early stages of melanoma regardless of the recurrence risk. Furthermore, prospective randomized data for determination of recurrence risk is lacking for this test. For these reasons, DecisionDx melanoma test performed on 11/9/16 was not likely to be more effective than the other methods for the evaluation of this patients medical condition.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2
A 54-year-old male enrollee has requested reimbursement for DecisionDx melanoma test performed on 11/9/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee who presented with a mole on his left upper back.   The physician reviewer found that melanoma is a cancer of the skin. Survival rates vary based on the depth of invasion of the primary tumor. Early stage tumors with negative sentinel lymph node biopsy carry a low risk of recurrence. Multiple analyses have demonstrated that survival/ prognosis is dependent upon tumor thickness, age at diagnosis, location of primary, presence of ulceration, mitotic rate, lymph node involvement, and growth pattern. Genomic and proteomic expression profiling has been under investigation, but the role in standard therapy has not been clearly outlined. DecisionDx test is a 15 gene panel expression assay which classifies based on a calculation from the gene expression and comparison with a training set of known outcomes. Multiple studies have been performed to validate its use and these small studies indicate that the score generated permitted clinicians to individualize the patient's surveillance plan. The National Comprehensive Cancer Network (NCCN) guidelines indicate that for melanoma, wide excision be pursued with sentinel lymph node evaluation if the tumor is greater than 0.75 mm thick. For stage IA, after resection observation is recommended whereas for stage IIB or IIC, interferon alpha should also be considered. There is a lack of current recommendations to undergo genomic or proteomic analysis to assess risk or assess benefit of adjuvant therapy. Due to the high risk of metastatic recurrence, evaluation of clinical and molecular characteristics is encouraged to guide surveillance care after local therapy as there is no definitive data on the optimal follow up after initial treatment. In this patients case, although DecisionDx provided an additional risk assessment tool, the current treatment and postoperative surveillance options available have proved to have limited impact on overall survival. Therefore, the utility of the score remains of limited utility. All told, DecisionDx melanoma test performed on 11/9/16 was not likely to be superior over the standard methods of evaluating this patient. Therefore, for the reasons stated above, the service at issue was not likely to have been 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 DecisionDx melanoma test performed on 11/9/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee who presented with a mole on his left upper back.   The physician reviewer found that 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 they suggest 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 the DecisionDx test for melanoma 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. As such, the test is novel and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. This was also the consensus opinion of the National Comprehensive Cancer Network (NCCN) guidelines. In sum, DecisionDx melanoma gene expression test performed on 11/9/16 was not likely to have been more beneficial than the standard treatment options for evaluating this patients medical condition. Therefore, for the reasons stated above, the service at issue was not likely to have been 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 40-year-old female enrollee has requested authorization and coverage for posterior lumbar interbody fusion (PLIF) spinal surgery. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees back pain. The physician reviewer found that evidence-based medical guidelines and peer-reviewed literature support lumbar fusion in the setting of disc pathology and degenerative disease when associated with evidence of spinal instability or surgically-induced temporary intraoperative instability, chronic pain, and failure of conservative treatment.  This patient reported a marked increase in her chronic low back pain and disability following a traumatic event in February 2016.  She has reported persistent and worsening low back pain with increasing levels of disability interfering with activities of daily living and work ability. Clinical findings are consistent with MRI and CT imaging evidence of nerve root compromise at the L4-5 and L5-S1 levels with bilateral pars defects at L5 and 4 mm lytic spondylolisthesis of L5 on S1. There was borderline instability documented at the L2-3 and L3-4 levels. Discogram confirmed concordant pain at the L4-5 level, with no concordant findings at L3-4. Detailed evidence of a recent, reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. The treating provider has planned complete facetectomies and foraminotomies to achieve adequate nerve root decompression which would result in temporary intraoperative instability in the pre-existent setting of spondylolisthesis and pars defects, and necessitate fusion. Therefore, the requested PLIF spinal surgery is medically indicated 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.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

The patient is a 42-year-old female who presented with a history of blood in her stool for at least six months. The patients medical history also includes nephrolithiasis. The colonoscopy note dated 10/13/17 reports finding of a 15 mm rectal polyp removed with snare cautery polypectomy, a 5 mm rectal polyp removed with a cold forceps, many small-mouthed diverticula in the sigmoid, transverse, and ascending colon, and a non-thrombosed external hemorrhoid on perianal examination. Per the patients letter, she has a family history of colon polyps. She reported that she underwent a colonoscopy and polypectomy on 10/13/17, and on 10/17/17, she had a large amount of bleeding 15-20 times, including near-syncope at 3:30 in the morning on 10/18/17. She presented to the hospital on 10/18/17. Per the emergency department note, the patients initial vital signs were normal. Per the hospital stay records, her initial hemoglobin was 11.2 g/dL, which decreased to 10.5 g/dL a few hours later. She was treated with one liter of intravenous fluids and she was discharged on 10/18/17. Per the gastroenterology consultation note dated 10/20/17, she had post-polypectomy bleeding, but did not require transfusions or sigmoidectomy. The patient has requested reimbursement for the one day acute inpatient stay provided on 10/18/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. In this case, the patient presented with a significant amount of bleeding following colonoscopy and polypectomy and marked anemia. Bleeding after snare cautery polypectomy can be severe, and therefore requires close monitoring. This condition may also require urgent intervention, including surgical or angiographic intervention when severe (Pasha, et al; Kim, et al; Jang, et al). Although the intensive care unit level of care was not needed given the patients normal vital signs, the inpatient level of care was appropriate given the rapidity of the bleeding and decline in hemoglobin. For these reasons, the one day acute inpatient stay provided on 10/18/17 was medically necessary for the treatment of this patients hematochezia.  Based on the foregoing discussion, the services at issue were 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 60-year-old female enrollee has requested authorization and coverage for Prolia. 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 Osteoporosis is an increasingly widespread condition. Fractures are the most dangerous aspect of osteoporosis, and this can lead to acute and chronic pain as well as increased mortality. A newer medication, denosumab (Prolia), is a fully human monoclonal antibody that has been approved for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone. The 2019 Endocrine Society guidelines on pharmacologic management of osteoporosis note that Prolia is indicated as an alternative initial treatment for postmenopausal women with osteoporosis at high risk for fracture. In this case, the patient has osteoporosis confirmed by DEXA scan and breast cancer, which increases her risk of osteoporotic fracture. Based upon clinical findings and the 2019 recommendations of the Endocrine Society, Prolia is a medically necessary initial therapy for osteoporosis. Therefore, Prolia is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of an eight-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) therapy, 13 hours per month of supervision and four hours per month of parent training provided from 4/29/16 through 10/29/16. 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 autism spectrum disorder.  The physician reviewer found that a nonsystematic review concluded that for best practice a minimum of 20 hours a week of intervention over two years, taking account of each childs strengths and weaknesses and family circumstances, was essential for young children with autism to make gains (Smith, et al; Roberts). In this case, the patient is in the first grade and is already having a school day of at least six hours. The request for 40 hour per week of ABA is excessive and may be detrimental of the desired effect. Therefore, based upon the medical literature and the documentation submitted for review, 20 hours per week of ABA therapy, 13 hours per month of supervision and four hours per month of parent training provided from 4/29/16 through 10/29/16 were and are medically necessary for treatment of the patients medical condition. Therefore, a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 54-year-old female enrollee has requested authorization and coverage for bilateral upper lid blepharoplasties with removal of excessive skin. The Health Insurer has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees bilateral functional ptosis. The physician reviewer found that in the medical literature, Cahill and colleagues noted that blepharoplasty indicators of improvement include margin reflex distance 1 (MRD(1)) of 2 mm or less, superior visual field loss of at least 12 degrees or 24%, down-gaze ptosis impairing reading and other close-work activities, a chin-up backward head tilt due to visual axis obscuration, symptoms of discomfort or eye strain due to droopy lids, central visual interference due to upper eyelid position, and patient self-reported functional impairment. An MRD-1 of 3 mm does not fulfill the current criteria for upper blepharoplasty regardless of the visual field interpretation and photographs provided for review. For these reasons, the requested bilateral upper lid blepharoplasties with removal of excessive skin is not supported as medically necessary for treatment of this patients excess skin. Based on the foregoing discussion, the requested service 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 Upheld

Summary Reviewer 

The parent of a 14-year-old male enrollee has requested reimbursement for psychological testing performed on 3/15/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had a previous diagnosis of attention deficit/hyperactivity disorder and had previous psychological testing prior to the disputed date of the requested testing.  Per the records, he was benefiting from his current outpatient psychotherapy, and his behaviors have improved in school over the past year. The records do not indicate why the testing would need to be repeated in this patients case. The documentation does not indicate that the patient had a low general cognitive ability or other neurological deficits that would require further and more complex evaluation. The current standard of care for diagnosis of attention deficit/hyperactivity disorder is a full clinical evaluation. Attention deficit/hyperactivity disorder is a clinical diagnosis. The medical evidence does not support the services at issue in this clinical setting. Thus, psychological testing performed on 3/15/18 was not medically necessary for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 53-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees prostate cancer. The physician reviewer found that according to the National Comprehensive Cancer Network (NCCN) guidelines, proton beam radiation therapy has not been demonstrated to provide superior health outcomes when compared to standard available radiation therapy for management of prostate cancer. In addition, proton beam radiation therapy is currently the subject of ongoing clinical trials. Overall, there is insufficient high quality clinical evidence to make conclusions about the relative safety and efficacy of proton beam radiation as compared with standard of care photon intensity modulated radiation therapy (IMRT). All told, the requested proton beam radiation therapy is not medically necessary for treatment of this patients prostate cancer. Based on the foregoing discussion, the requested services are 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 

The parent of a 14-year-old female enrollee has requested reimbursement for acute psychiatric inpatient treatment provided from 10/19/18 through 11/02/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining necessary level of care for children. As of 10/24/18, with regards to risk of harm, the records support a score of 2 due to a lack of a history of suicidal ideation but behaviors, including refusal to eat, which could cause self-harm, even unintentionally. In terms of functional status, the records support a score of 3. The records indicated that the patient had issues with role performance due to psychiatric symptoms. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 2. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a stable living environment. With regards to resiliency and treatment history, the records support a score of 3. There was no clear evidence of long-term treatment outcomes. In terms of acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy and followed the meal plan as directed. With regards to acceptance and engagement of the parent, the records support a score of 2. The patients parents worked actively and constructively with clinicians. Thus, the patient had a composite score of 16. This score correlates with intensive outpatient services. Thus, acute psychiatric inpatient treatment provided from 10/19/18 through 10/24/18 was medically necessary for the treatment of this patient. The submitted documentation fails to demonstrate the medical necessity of the remaining dates of services at issue. Therefore, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 62-year-old female enrollee has requested reimbursement for genetic testing performed on 7/31/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation for the evaluation of the enrollees medical condition. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch, with some minor updates. Mitotic index has also been thought to add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the risk of metastasis. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma class, in patients undergoing sentinel node biopsy. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear if the DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, testing (DecisionDx-Melanoma Gene Assay) performed on 7/31/18 was not likely to have been more beneficial than other methods of evaluating this patient.