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

Summary Reviewer 3

A 57-year-old female enrollee has requested reimbursement for DecisionDX-melanoma gene expression test performed on 8/12/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees left cutaneous melanoma. The physician reviewer found that the 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 is also a lack of consistency between various genes being used as biomarkers. As such, the test is very 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. All told, DecisionDX-melanoma gene expression test performed on 8/12/16 was not likely to have been superior over other methods of 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 64-year-old female enrollee has requested reimbursement for genetic testing performed on 11/30/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who was diagnosed with breast cancer. The physician reviewer found that this patient had biopsy proven DCIS with extensive microcalcifications indicated on MRI. OncotypeDX was used to determine the risk of invasion in order to determine surgical decision making regarding lumpectomy versus mastectomy. However, OncotypeDX DCIS was developed to determine the need for radiation post-lumpectomy and not for surgical decision making. In addition, data regarding utility are still preliminary. This patient had extensive calcifications and the standard of care would be to biopsy the calcifications to determine the extent of the disease and to determine whether or not to proceed with mastectomy versus breast conserving therapy. As such, this test was not used in the correct context and was not likely to be more beneficial than the standard of care of using clinical factors to choose the extent of therapy. Therefore, for the reasons stated above, the services at issue were not likely to have been 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 Overturned

Summary Reviewer 2

A 64-year-old female enrollee has requested reimbursement for genetic testing performed on 11/30/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who was diagnosed with breast cancer. The physician reviewer found OncotypeDX breast cancer assay uses reverse transcriptions polymerase chain reaction to assess the genomic profile by analyzing the tumor tissue with a panel of 21 genes. There is data which supports use of this assay for patients with DCIS or early stage invasive ductal adenocarcinoma to help direct care. For this patient, the report indicated a 20% risk of a recurrent event when the biopsy was examined. The surgical specimen analysis was associated with a 34% risk of recurrence of invasive disease. Studies assessing the benefit of the OncotypeDX recurrence score assay provides a prediction regarding locoregional and distant recurrence for postmenopausal women treated with tamoxifen or those treated with an aromatase inhibitor. There have also been studies that demonstrate its ability to predict response to adjuvant therapy. High scores indicated benefit from chemotherapy and low scores, regardless of lymph node involvement, did not appear to benefit. Recent data has validated the use of OncotypeDX in DCIS. It analyzes 12 genes instead of 21. The use of OncotypeDX has been validated in multiple studies but is not included in current treatment guidelines. However, in this patients clinical case, the use of OncotypeDX at two different time points helped guide the surgeon and the patient. Without the genetic testing, this patient would not have undergone mastectomy and the invasive component may not have been detected. Since current guidelines give the option of chemotherapy and Herceptin (category 2B) then the OncotypeDX performed on 11/30/16 helped direct this patients postoperative treatment plan. All told, the genetic testing performed on 11/30/16 was likely to have been more effective than the standard options for evaluation of 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 Overturned

Summary Reviewer 3
A 64-year-old female enrollee has requested reimbursement for genetic testing performed on 11/30/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who was diagnosed with breast cancer. The physician reviewer found that the OncotypeDX test is a gene expression assay that generates a DCIS score that may predict the occurrence of ipsilateral invasive breast cancer. The gene expression test was prospectively analyzed in clinical trial E5194, where 327 women with DCIS were stratified into low, intermediate, and high scores, which predicted for either DCIS recurrence or invasive breast cancer in the ipsilateral breast. The test may be used to better assess the utility of radiation therapy after a lumpectomy. The patient under discussion had a complex situation where normal pathology biomarkers were not well suited to address whether a lumpectomy and radiation therapy were appropriate therapies versus total mastectomy.  In sum, the genetic testing performed on 11/30/16 was likely to have been more beneficial than the standard alternatives for evaluation of this patient. 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 Overturned

Summary Reviewer 1

A 50-year-old female enrollee has requested reimbursement for the injection of periurethral bulking agent provided on 12/19/14. The Health Insurer has denied this request indicating that the service at issue was considered investigational for treatment of the enrollees recurrent stress urinary incontinence and intrinsic urethral sphincter deficiency.   The physician reviewer found that this patient presents with persistent stress urinary incontinence associated with urgency and urgency incontinence. She underwent multiple procedures which failed. Subsequently, the patient underwent urethral bulking agent injection therapy. The patient did undergo preoperative urodynamics. There was cystoscopy evidence that the patient had urethral hypermobility and the patient also had urgency. However, there was no evidence of an intrinsic sphincteric deficiency. At this time, the success rate for long-term urethral bulking agent therapy is significantly low and alternative surgical procedures would likely have provided this patient with a superior health outcome. Accordingly, the injection of periurethral bulking agent provided on 12/19/14 was not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Based upon the information set forth above, the service 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 Overturned

Summary Reviewer 2

A 50-year-old female enrollee has requested reimbursement for the injection of periurethral bulking agent provided on 12/19/14. The Health Insurer has denied this request indicating that the service at issue was considered investigational for treatment of the enrollees recurrent stress urinary incontinence and intrinsic urethral sphincter deficiency.   The physician reviewer found that the injection of coaptite for urinary stress incontinence is an acceptable treatment for urinary stress incontinence in well selected patients. The procedure can be performed under local anesthesia and there is usually an immediate improvement in the patients stress incontinence. Although there are other viable treatment options, this procedure is likely to be more beneficial. Thus, the injection of periurethral bulking agent provided on 12/19/14 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, the service 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 3

A 50-year-old female enrollee has requested reimbursement for the injection of periurethral bulking agent provided on 12/19/14. The Health Insurer has denied this request indicating that the service at issue was considered investigational for treatment of the enrollees recurrent stress urinary incontinence and intrinsic urethral sphincter deficiency.   The physician reviewer found that endoscopic bulking is an accepted option specifically under this clinical scenario as noted in the American Urological Association (AUA) guidelines on incontinence. There is adequate data that endoscopic bulking is the least invasive among the available treatment options and most likely to improve this patients clinical concern of stress incontinence with intrinsic sphincter deficiency. All told, the injection of periurethral bulking agent provided on 12/19/14 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, the service 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 64-year-old female enrollee has requested reimbursement for ChemoFx Assay testing performed on 9/30/13.  The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees ovarian cancer.The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the testing at issue. In vitro drug testing on patients tumor cells prior to applying chemotherapy is an attractive idea but it is difficult to put into clinical use. The most thorough evaluation of these technologies was performed by the American Society of Clinical Oncology. In their review of this technology the panel concluded that in vitro drug testing should be limited to clinical trials (Schrag, et al). Moreover, the Physicians Data Query of the National Cancer Institute does not specifically recommend the ChemoFx Assay to direct therapy. In the clinical setting of newly diagnosed ovarian cancer there is extensive clinical data supporting the first-line use of paclitaxel and carboplatin. For the reasons provided, ChemoFx Assay testing performed on 9/30/13 was not medically necessary for evaluation of this patients medical condition. Therefore, the Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 52-year-old male who has a history of chronic low back pain. The patient has requested authorization and coverage for an MRI. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient. The physician reviewer found that when to obtain specialized cross-sectional imaging of the spine is a difficult decision. Pain is a very common complaint, and not everyone who has pain needs a computed tomography (CT) or MRI scan. As a fundamental principle, an imaging study should affect the management of the patient. In this patientas case, although his pain may be significant, a more conservative management would be optimal at this point, at least until it is proven that a conservative approach is unsuccessful, and surgery or interventions should be deferred until absolutely necessary. At this point, it is unclear whether plain x-rays are warranted. This is not to say that plain x-rays might not provide some information, but the possible finding of degenerative change on plain x-rays would also not change the immediate management. As has been shown in multiple studies, incidental finding of degenerative disease or disc abnormality is exceedingly common in asymptomatic individuals. It is well known that some patients with substantial MRI findings will not have symptoms, and conversely, some patients with minimal signs on MRI will have pronounced symptoms. The American College of Radiology (ACR) has established aAppropriateness Criteriaa to help referring physicians obtain efficient use of imaging modalities to evaluate various clinical presentations. The ACR has established these criteria for chronic neck and low back pain. MRI is felt to be anot usually appropriatea in the management of chronic pain without other red flags. On physical examination, other than the pain, there is no submitted information regarding loss of strength or loss of reflexes or other symptoms, such as incontinence. There is no evidence of prior tumor or infection. While it is always possible that random testing of any organ will demonstrate a significant finding, the likelihood is slim. Based on the submitted records, a lumbar spine MRI is not medically indicated. Therefore, the requested MRI is not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 26-year-old male enrollee has requested authorization and coverage for Xyrem. 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 the patients history of excessive daytime sleepiness and the MSLT with normal polysomnography are consistent with the narcolepsy diagnosis. The interpreting sleep physician explained that the patient met the criteria in the first four naps. It is usually acceptable not to conduct the fifth nap if the first four naps are consistent with the diagnosis. Thus, the records confirm the diagnosis of narcolepsy. In this patients case, it appears as if a stimulant alone is not enough to control the patients symptoms. Untreated or undertreated narcolepsy can lead to accidents. Therefore, Xyrem is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 63-year-old female who has requested reimbursement for harvest auto stem cells provided on 1/28/19 and 1/29/19. She has a history of multiple myeloma. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Autologous stem cell transplantation is considered a standard of care in the treatment of multiple myeloma with a good response after primary therapy. This approach is supported by the National Comprehensive Cancer Network (NCCN) guidelines. Stem cell collection from the patient after stimulation of the bone marrow to produce increased stem cells is also standard. Therefore, harvest auto stem cells provided on 1/28/19 and 1/29/19 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 57-year-old male enrollee has requested reimbursement for conjunctivorhinostomy without tube (CPT 68745) for performed on 10/21/14.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees blocked tear duct with a possible stone. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity for the services at issue. Conjunctival dacryocystorhinostomy is generally the standard approach in treating epiphora caused by lower lacrimal tract obstruction. However, conventional dacryocystorhinostomy works well for the lower drainage system, but not as well for the upper system. In this case, the patient underwent conjunctivorhinostomy for the treatment of upper lacrimal drainage system. Therefore, the conjunctivorhinostomy without tube (CPT 68745) for performed on 10/21/14 was medically necessary in this patients case. For the reasons provided, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 60-year-old female enrollee has requested authorization and coverage for peroral endoscopic myotomy (POEM) and associated inpatient admission. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees esophageal achalasia. The physician reviewer found that POEM is a U.S. Food and Drug Administration (FDA) approved treatment for achalasia. In this case, the patient is status post orthotopic liver transplant which was complicated by biliary leak. The patient is not a candidate for surgical treatment. Given the patients severe achalasia and lack of surgical option, POEM is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. For the reasons provided, the request for POEM and associated inpatient admission are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 60-year-old female enrollee has requested authorization and coverage for peroral endoscopic myotomy (POEM) and associated inpatient admission. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees esophageal achalasia. The physician reviewer found that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient is status post orthotopic liver transplant and has evidence of achalasia. In this clinical setting, treatments include laparoscopic Heller myotomy with partial fundoplication and POEM. Because the patient is status post orthotopic liver transplant with a history of bile leak, Heller myotomy is likely contraindicated. As such, the request for POEM and associated inpatient admission are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 60-year-old female enrollee has requested authorization and coverage for peroral endoscopic myotomy (POEM) and associated inpatient admission. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees esophageal achalasia. The physician reviewer found that the request for POEM and associated inpatient admission is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. POEM is a minimally invasive treatment for achalasia, and there is sufficient peer reviewed data to substantiate its safety and efficacy. Teitelbaum and colleagues studied patients who underwent POEM for treatment of esophageal motility orders. The authors reported that POEM resulted in successful palliation of symptoms in the majority of patients after five years. In this case, the patient is a good candidate for this minimally invasive therapy. POEM obviates the need for operative exploration and dealing with expected adhesive disease from her transplant. Therefore, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 60-year-old female 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.  In treatment-naive patients with hepatitis C, genotype 1 infection, treatment with Harvoni is recommended.  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, 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.