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

Summary Reviewer 


A 25-year-old male enrollee has requested reimbursement for substance abuse residential treatment services provided from 7/22/17 through 8/3/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance and alcohol abuse. The physician reviewer found that the patients post-acute withdrawal symptoms were not severe in nature. He was not a danger to himself or others, nor was he aggressive. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant residential level of care. He had no comorbid medical conditions and he was psychiatrically stable. His medications could have been managed in an ambulatory setting. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He was motivated and working the program. He was cooperative and participating in his treatment plan. Although the patient continued to require further treatment to develop and solidify coping skills, this did not require the residential structure. No new problems had arisen and there was no evidence to indicate that returning him to his environment would lead to destabilization. Thus, as of 7/22/17, the patient no longer met the criteria for residential level of care. Accordingly, the substance abuse residential treatment services provided from 7/22/17 through 8/3/17 were not medically necessary for treatment of the patients medical condition. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 66-year-old female enrollee has requested authorization and coverage for Inspire upper airway stimulation system. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas obstructive sleep apnea. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. The patient has obstructive sleep apnea and has no nasal obstruction. She has not been able to tolerate continuous positive airway pressure therapy. The Inspire device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of obstructive sleep apnea. At this point, the patient is a candidate for the Inspire device, given the intolerance to continuous positive airway pressure therapy, anterior posterior collapse, no central apnea, and body mass index and apnea-hypopnea index within FDA criteria. Therefore, Inspire upper airway stimulation system is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 66-year-old female enrollee has requested authorization and coverage for Inspire upper airway stimulation system. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas obstructive sleep apnea. The physician reviewer found that there is sufficient support for the requested services in this patientas case. She has failed continuous positive airway pressure therapy and is not an optimal candidate for oral appliance therapy due to the severity of her obstructive sleep apnea. The alternative, no treatment, may lead to potential harms, such as increased medical comorbidities, including hypertension, diabetes, congestive heart failure, myocardial infarction, and stroke. There is sufficient evidence in the peer-reviewed literature to support the safety, efficacy, and long-term outcome in the treatment of obstructive sleep apnea with hypoglossal nerve stimulation or Inspire airway stimulation. Multiple published studies show clinically significant decreases in observed mean apnea-hypopnea index and Epworth Sleepiness Scale scores.  The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be a safe and effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy. Therefore, Inspire upper airway stimulation system is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 66-year-old female enrollee has requested authorization and coverage for Inspire upper airway stimulation system. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas obstructive sleep apnea. The physician reviewer found that the Inspire device has been approved by the FDA for the treatment of moderate to severe obstructive sleep apnea refractory to continuous positive airway pressure therapy. However, a meta-analysis by Kompelli and colleagues found that contemporary hypoglossal nerve stimulation research consisted of single-arm clinical trials and case series, with a high likelihood of publication bias and a lack of comparative trials of hypoglossal nerve stimulation versus existing alternatives, such as upper airway surgery. They concluded that hypoglossal nerve stimulation amay not be the definitive choice for second-line therapya for obstructive sleep apnea. Overall, there is insufficient high-quality, peer-reviewed evidence to support the use of hypoglossal nerve stimulation over other available therapies. Therefore, Inspire upper airway stimulation system is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 59-year-old male has requested authorization and coverage for CPT 43210 (transoral incisionless fundoplication procedure utilizing the EsoPhyx device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees gastroesophageal reflux disease. The physician reviewer found that there is a lack of support for the requested services in this clinical setting. This patient has pathologic acid reflux. With regards to the requested procedure, there is a lack of long-term studies with a substantial number of patients beyond one year. In addition, many patients who undergo transoral incisionless fundoplication are subsequently on proton pump inhibitor therapy for rescue therapy six months later. There is a paucity of long-term studies comparing transoral incisionless fundoplication to surgical fundoplication. Therefore, CPT 43210 (transoral incisionless fundoplication procedure utilizing the EsoPhyx device) is not likely to be more effective than other treatment options. 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 59-year-old male has requested authorization and coverage for CPT 43210 (transoral incisionless fundoplication procedure utilizing the EsoPhyx device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees gastroesophageal reflux disease. The physician reviewer found that the efficacy of transoral incisionless fundoplication using the EsophyX device has been studied in randomized controlled trials. However, the conclusions are contradictory. Witteman and colleagues performed a large randomized trial which included 60 patients. The authors found no improvement in esophageal acid exposure compared with baseline at 12 months. Normalization of pH was accomplished in only 29% in conjunction with deteriorated valve appearances at endoscopy and resumption of proton pump inhibitor therapy in 61%. The study concluded that no long-term objective reflux control was achieved. The 2013 American College of Gastroenterology guidelines for treatment of gastroesophageal reflex disease reported that the usage of current endoscopic therapy or transoral incisionless fundoplication cannot be recommended as an alternative to medical or traditional surgical therapy (moderate level of evidence). Numerous published series have reported significant adverse events, and there is a lack of sham-controlled trials comparing transoral incisionless fundoplication with anti-reflux surgery. All told, CPT 43210 (transoral incisionless fundoplication procedure utilizing the EsoPhyx device) is not likely to be of greater benefit than other treatment options. 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 3

A 59-year-old male has requested authorization and coverage for CPT 43210 (transoral incisionless fundoplication procedure utilizing the EsoPhyx device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees gastroesophageal reflux disease. The physician reviewer found that appropriate patient selection is crucial before anti-reflux procedures. Transoral incisionless fundoplication has shown durable response for a select population of gastroesophageal reflux disease patients. However, the severity of this patients esophageal dysmotility disqualifies him as an ideal candidate for the proposed transoral incisionless fundoplication procedure. As such, CPT 43210 (transoral incisionless fundoplication procedure utilizing the EsoPhyx device) is not likely to be more efficacious than other treatment options. 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 62-year-old male who presented with prostate cancer and underwent a radical prostatectomy in 2008. The patient has requested authorization and coverage for radiation therapy for prostate cancer. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that this patients pathologic specimen reveals lymph node disease with no evidence of distant metastases. Due to the localized disease presentation, radiation therapy is indicated and is potentially curative. The radiation technique of intensity modulated radiation therapy is necessary due to the patient receiving prior radiation to the pelvic region. Intensity modulation in this setting is necessary to reduce the dose to the surrounding small bowel, which will reduce long-term toxicities from the treatment. As this is a relatively rare clinical presentation with nodal only relapse of prostate cancer, there is a lack of phase 3 studies or guidelines that specifically address treatment in this scenario. However, there are multiple large retrospective series that indicate that salvage radiation therapy in this setting can result in long-term cure rates with minimal toxicities.  Therefore, radiation therapy for prostate cancer is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The patient is a 62-year-old male who had developed malignant melanoma on the skin of left parietal scalp above the ear, 1.0 mm in Breslow thickness. The DecisionDx-Melanoma gene assay performed on 1/12/17 revealed class 1A molecular signature associated with a low risk of recurrence within five years. The patient has requested reimbursement for the DecisionDx-Melanoma test (84999) performed on 1/12/17. The Health Insurer denied this request for reimbursement and noted that the services at issue were considered investigational for evaluation of this patient. There is some support for the DecisionDx-Melanoma signature as an independent predictor of metastasis risk. However, there is a lack of peer reviewed published studies as to its superior efficacy when compared to other standard modalities. Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. DecisionDx-Melanoma assay 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. While the majority of clinical stage I patients will be disease free at five years, some stage I patients will develop advanced disease. According to the results of analysis of this patients melanoma performed with DecisionDx-Melanoma assay, the tumor was classified as class 1 with a low risk of near term (within five years) metastatic disease. In sum, while there is some support in the medical literature for the efficacy of the services at issue, DecisionDx-Melanoma test (84999) performed on 1/12/17 was not likely to have been of greater benefit than the available standard methods for the evaluation of patient. Therefore, for the reasons stated above, the services at issue were 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 2

The patient is a 62-year-old male who was diagnosed with a melanoma on his left parietal scalp with a Breslow depth of at least 1mm.  The patients physician sent his tissue for molecular genetic testing to help determine the risk of spread of the tumor. The patient has requested reimbursement for the DecisionDx-Melanoma test (84999) performed on 1/12/17. The Health Insurer denied this request for reimbursement and reported that the services at issue were considered investigational for evaluation of this patient. In this case, the patient has a scalp/head melanoma. These cancers are associated with a lower yield on sentinel lymph node biopsy (SNLB). His tumor is transected at the base so the records do not provide an accurate Breslow depth but we know it is at least 1 mm.  In order to be able to follow this patient most effectively in terms of risk of recurrence, a molecular study that shows the risk of recurrence would be most helpful. This study would help to stratify this patients risk of recurrence of his tumor after a wide resection. This patients risk would then be used to determine potential treatment and follow up.  In this case, since the SNLB is likely to be negative and it would be difficult to obtain an accurate risk of recurrence, the DecisionDx-Melanoma assay was likely to yield a better result. A complete lymph node dissection is also more difficult in head tumors as they can involve extensive parotid or neck surgeries. All told, the results from DecisionDx-Melanoma test (84999) performed on 1/12/17 was likely to have been more efficacious than the standard options of evaluating this patients medical condition. Therefore, for the reasons stated above, the services at issue were likely to have been 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 3

The patient is a 62-year-old male who has been diagnosed with melanoma of at least 1.0 mm Breslow depth on the left parietal scalp. The provider sent a sample tissue for testing to assess metastatic risk. The patient has requested reimbursement for the DecisionDx-Melanoma test (84999) performed on 1/12/17. The Health Insurer denied reimbursement and reported that the services at issue were considered investigational for the evaluation of this patients medical condition. The National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting as it is considered to be investigational. The use of this type of testing is not considered to be standard of care in this clinical setting. Thus, its use is not expected to affect the treatment of this patients melanoma. As such, the results from DecisionDx-Melanoma test (84999) performed on 1/12/17 was not likely to have been superior over the other standard treatment options for the evaluation of this patient.  Therefore, for the reasons stated above, the services at issue were 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 Upheld

Summary Reviewer 


A 36-year-old female enrollee has requested reimbursement for reduction mammoplasty performed on 7/28/16. The Health Insurer has denied this request indicating that the surgery at issue was not medically necessary for treatment of the enrollees macromastia. The physician reviewer found that according to the patients letter, her complaints included neck, shoulder and back pain due to her large breasts. These are the typical complaints of women with macromastia. However, this patients records do not support the medical necessity of reduction mammoplasty. There were no photographs provided for review and the records do not include any supporting documentation from the patients primary care provider that confirms the presence of disabling musculoskeletal symptoms from macromastia. An operative or pathology report documenting the weight of the reduction was also not provided. A work-up for other possible causes of her symptoms is not documented, and she has not reportedly been evaluated by a musculoskeletal specialist. The records do not include any documentation that attempts at medical treatment for chronic musculoskeletal pain such as chiropractic care, physical therapy, analgesics or support bras. In this case, only the plastic surgeons notes describe musculoskeletal pain. Confirmatory evidence of symptoms, such as a history of conservative therapy, photographic evidence of severe breast hypertrophy or a history of frequent primary care physician visits for musculoskeletal symptoms is necessary to support the history provided by the plastic surgeon. All told, the reduction mammoplasty performed on 7/28/16 was not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the surgery at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 63-year-old female enrollee has requested reimbursement for unlisted laboratory services provided on 7/02/19 and 1/28/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that ClonoSEQ assay is a very sensitive genetic assay that can detect very minimal numbers of residual myeloma cells. It is used often in clinical trial situations to determine the efficacy of treatment. Munshi and colleagues performed a meta-analysis, and the assay has been shown to correlate with both progression-free survival and overall survival. It is becoming more commonly used to accurately guide therapy. The National Comprehensive Cancer Network recommends its use. Therefore, unlisted laboratory services provided on 7/02/19 and 1/28/20 were likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 63-year-old female enrollee has requested reimbursement for unlisted laboratory services provided on 7/02/19 and 1/28/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that ClonoSEQ is a type of next-generation sequencing used to evaluate for minimal residual disease (MRD). It has been approved by the U.S. Food and Drug Administration (FDA) for MRD assessment in myeloma. A baseline sample is required to identify the dominant clonotype, but the study can be performed on both fresh and stored samples. It is not impacted by therapeutic monoclonal antibodies. The National Comprehensive Cancer Network (NCCN) guidelines recommend consideration of using MRD for monitoring patients. The patient has had two tests, the first in 2019 to establish a baseline and the most recent to evaluate response to current therapy. There is sufficient support for the services at issue in this setting. Therefore, unlisted laboratory services provided on 7/02/19 and 1/28/20 were likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 63-year-old female enrollee has requested reimbursement for unlisted laboratory services provided on 7/02/19 and 1/28/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that this patient had a standard therapeutic approach for the treatment of multiple myeloma.  A new advance in the care of myeloma has been the analysis of minimal residual disease (MRD) by next generation sequencing. The test that is being used here is the ClonoSEQ testing. According to the National Comprehensive Cancer Network guidelines, the identification of the myeloma clone can be done at the time of diagnosis and also followed up during surveillance. The discussion within the National Comprehensive Cancer Network group and the current guidelines state, aMRD has been identified as an important prognostic factor. A prospective study of patients with newly diagnosed multiple myeloma evaluated MRD bone marrow samples and showed that had a median follow-up of 57 months MRD negativity after autologous stem cell transplant translated to significantly improved progression free survival and overall survival rates.a  Based on the current medical evidence, the testing as ordered was appropriate for this patient. Therefore, unlisted laboratory services provided on 7/02/19 and 1/28/20 were likely to have been more beneficial than other methods of evaluating this patient.