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

Summary Reviewer 1

A 54-year-old male has requested reimbursement for genetic testing performed on 2/04/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found that Foundation One assay is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay would identify a specific target which could inform the clinician as to what chemotherapeutic agent would be useful. Thus far, however, there is a lack of convincing evidence that the assay adds to the decision-making ability or yields a result that is reliably clinically beneficial.  There are a variety of non-randomized studies exploring the value of molecular profiling, none of which have offered convincing evidence of the efficacy of this approach.  A randomized study by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular assay versus by the oncologists clinical judgment. The demonstration of a mutation on assay does not guarantee that a drug targeted at the mutation will be useful.  In sum, genetic testing performed on 2/04/16 was not likely to have been superior over other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 54-year-old male has requested reimbursement for genetic testing performed on 2/04/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer.The physician reviewer found that Foundation One testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers than can help guide therapy decision making. Per the National Comprehensive Cancer Network guidelines, it has not been determined if molecular markers are useful in treatment determination (predictive markers) and prognosis other than KRAS, NRAS, and BRAF mutations. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. Per the medical evidence, Foundation One testing was unlikely to be more beneficial than any available standard therapy such as testing the tumor for standard markers, such as KRAS, NRAS, and BRAF. All told, genetic testing performed on 2/04/16 was not likely to have been superior over other available methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 54-year-old male has requested reimbursement for genetic testing performed on 2/04/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer.The physician reviewer found that patients with refractory or relapsed cancer that have exhausted standard treatments are usually considered for clinical trials. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Von Hoff and colleagues performed a study of 86 patients where the progression-free survival on the regimen selected by molecular profiling was compared to the progression-free regimen on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. Genetic testing may be highly informative. For example, KRAS and BRAF mutations may inform therapy decisions. KRAS is one of the most frequently mutated oncogenes in colorectal cancer (35-45% of patients).  The gain of function mutations most commonly occur in codon 12 or codon 13.  In several clinical trials, mutation in KRAS is associated with worse progression-free survival compared to patients with wild type KRAS when treated with monoclonal antibody directed against EGFR in combination with chemotherapy.  In one large randomized clinical trial where FOLFIRI was tested with or without Erbitux, KRAS mutation status did not significantly affect progression-free survival. There is published data from a large retrospective trial that the presence of the BRAF mutation provides additional prognostic information with regards to cetuximab treatment. The MEK kinases are within the same pathway as RAS and BRAF. Mekinist or trametinib is a new inhibitor of MEK kinases approved for use in metastatic melanoma with mutant BRAF.  In this patients case, the results from molecular profiling offers a rational selection of the next regimen. Thus, genetic testing performed on 2/04/16 was likely to have been more efficacious than other standard methods of evaluating this patient. 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 Upheld

Summary Reviewer 1


A 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort.The physician reviewer found in this case, the medical records fail to indicate any diagnosis consistent with an IgG mediated food allergy to support an indication for the testing at issue. The current National Institutes of Health National Institute of Allergy and Infectious Disease expert panel states that IgG food testing is not validated (Boyce, et al). The Joint Task Force on Practice Parameters for the Allergy and Immunology also state that IgG food testing is not validated (Sampson, et al). As such, IgG food testing is not considered the standard of care in this clinical setting (Sicherer and Teuber). Thus, the IgG food sensitivity testing performed on 2/10/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


A 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort. The physician reviewer found based on the current literature and guidelines that address IgG diagnostic testing, IgG food sensitivity testing is not considered a clinically useful, relevant, or valid method for evaluation of abdominal discomfort, or for identifying food allergy or food intolerance that may be contributing to abdominal discomfort or other gastrointestinal symptoms. IgG and IgG subclass antibody tests for food allergy related conditions do not have clinical relevance and lack sufficient quality control, and should not be performed (Boyce, et al). All told, the IgG food sensitivity testing performed on 2/10/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort.  The physician reviewer found the use of food-specific IgG level testing has not been shown to improve health outcomes at long-term follow-up. There is data suggesting that this testing does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance. Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods (Beyer and Teuber). Thus, food-specific IgG should not be used as a tool to diagnose food allergy and the positive foods should not be eliminated from the diet based upon results of these tests (Lemon-Mule, et al; Savilahti, et al). The standard evaluation of food allergy consists of blood IgE level for foods and skin testing. IgE immunoassays are in vitro assays used to identify food-specific IgE in the serum. Immunoassays have demonstrated very high positive predictive accuracy for several of the major food allergens including egg, milk, peanut, tree nuts, and fish that correspond to a positive predictive accuracy of 95%. Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies. A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food. A negative skin test result indicates the absence of an IgE-mediated allergy upon subsequent challenge with a 90 to 95% predictive accuracy. In conclusion, the IgG food laboratory testing performed on 2/10/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard of care.Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 46-year-old male enrollee has requested reimbursement for collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral corneal ectasia. The physician reviewer found that there is sufficient support for the superior efficacy of the services at issue in this patients case. Collagen crosslinking procedure has been well studied as a treatment option for corneal ectasia and to stabilize vision loss. Based on the patients vision loss and progression, crosslinking was the most appropriate and effective treatment available.  The services at issue are not considered experimental. Instead, crosslinking is validated by the medical literature findings. There is a large body of evidence demonstrating that this treatment is safe and effective for post refractive ectasia. This includes recent prospective placebo controlled trials with a large number of patients that demonstrate the effectiveness of stabilizing corneal ectasia and potentially delaying or preventing the need for full thickness corneal transplant.  Furthermore, corneal collagen crosslinking for corneal ectasias fulfills an unmet need. There is very few treatment options available to slow or halt disease progression. As such, treatment for this patients condition with collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16 was likely to have been more effective than any other available option for this patient. Based upon the information set forth above, the services at issue were 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 46-year-old male enrollee has requested reimbursement for collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral corneal ectasia. The physician reviewer found that Corneal crosslinking is a U.S. Food and Drug Administration (FDA) approved procedure for corneal ectasia and post refractive ectasia.  The primary purpose of crosslinking is to halt the progression of corneal thinning that occurs with conditions such as keratoconus and post refractive corneal ectasia. The procedure involves soaking the corneal stroma with riboflavin and then using ultraviolet light to create chemical bonds between collagen fibrils within the stroma.  This stiffens the cornea and halts the thinning.  Prior to this treatment, patients with keratoconus who failed medical treatment (glasses, contact lenses) and whose disease continued to progress would go on to surgical management with corneal transplantation. There have been multiple studies published which demonstrate that patients who underwent corneal crosslinking showed an improvement in keratometry values, uncorrected visual acuity and best corrected visual acuity in contrast to sham group. Of note, this procedure is not considered a refractive or vision correcting as the primary purpose of crosslinking is to stabilize the cornea and prevent further thinning and bulging that is seen with keratoconus and post refractive ectasias. In addition, there have been studies that have shown an overall decrease in the number of penetrating keratoplasties performed since the introduction of crosslinking.  There is mounting evidence of the benefit of this treatment in patients diagnosed with keratoconus and post refractive ectasias who have progressive disease. Given the patients topographic evidence of post refractive ectasia, as well as the evidence of progressive disease, collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16 were likely to have been superior over any other methods for treatment of this patients medical condition. Based upon the information set forth above, the services at issue were 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 46-year-old male enrollee has requested reimbursement for collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral corneal ectasia. The physician reviewer found that the medical literature supports the efficacy of the services at issue in this clinical setting. Collagen crosslinking is a standard treatment for progressive keratoconus and ectasia after refractive surgery. It was approved by the U.S. Food and Drug Administration in 2016. There are many case series showing the efficacy in post Lasik ectasia. In order to determine if a patient is an appropriate candidate for collagen crosslinking, one must have evidence of progression, which can be based on refraction, keratometry, topography, or objective testing measures. In this patients case, the records from the patients provider noted evidence of progression. Given the likelihood of progression, collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16 were likely to have been the most effective treatment option for this patient.
Based upon the information set forth above, the services at issue were 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 43-year-old transgender female enrollee has requested authorization and coverage for electrolysis epilation, each 30 minutes. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found the requested services are within accepted standard of practice and clinically appropriate for treatment of this patients gender dysphoria. In this case, the patient is well-documented to have gender dysphoria; thus, her external anatomy should be more consistent with a female than a male. She has transitioned into living as a female since she began hormone therapy in 2013. The requested epilation hair removal can provide substantial improvement in the appearance of terminal hair and create as normal an appearance as possible. Moreover, the requested treatment may improve emotional function in this patient. It would create a more feminine genital or extremity appearance. The medical literature support the services at issue for treatment of gender dysphoria. Therefore, for the reasons stated above, 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 Upheld

Summary Reviewer 

A 35-year-old female enrollee has requested authorization and coverage for surgical jaw reconstruction. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the medical necessity for the requested surgical jaw reconstruction has not been established in this clinical setting. The patient presents with a class II malocclusion and has been recommended to undergo orthodontic appliances and double jaw surgery. However, a clear functional deficit related to this malocclusion that has failed reasonable conservative management and would likely improve with complex surgical intervention has not been adequately defined in the medical documentation. The patient complains of discomfort and intermittent pain. However, it is not clear from the requesting surgeon that this is from the malocclusion and that this would likely improve with surgical correction, as he states that this may or may not improve with jaw repositioning and correction of her occlusion. In addition, based on the photographs, the patient does not have evidence of significant disfigurement from her malocclusion and overjet. Therefore, the requested procedures are not considered medically necessary, as there is not a well-defined functional impairment that would likely improve with surgical intervention. Moreover, based on the photographs submitted for review, the patient does not have evidence of significant deformity to warrant surgical correction on a reconstructive basis.
Therefore, the requested services are 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 32-year-old female enrollee has requested reimbursement for prenatal testing performed on 1/10/14. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees suspected fetal abnormality. The physician reviewer found, while cell-free fetal DNA testing is a very effective screening test for women at high risk for fetal trisomy, the use of this test for lower risk women has not been established.  The American Congress of Obstetricians and Gynecologists (ACOG) currently states Given the performance of conventional screening methods, the limitations of cell-free DNA screening performance, and the limited data on cost-effectiveness in the low-risk obstetric population, conventional screening methods remain the most appropriate choice for first-line screening for most women in the general obstetric population. Since this patients risk of Down syndrome at the time of testing was appropriately assessed as 1:5,000, she would not be classified as at high-risk for fetal trisomy. The data underlying this recommendation comes from the Non-Invasive Chromosomal Evaluation (NICE) Study that only included patients with an increased risk of fetal aneuploidy, with a presumed prevalence of trisomy 21 of 1:50 in their cohort. More recent studies on cell-free DNA testing in a low risk or routine population has confirmed [cell-free DNA] cfDNA testing was superior to that of traditional first-trimester screening for the detection of trisomy 21 in a routine prenatal population, but indicates further study is still needed (Norton, et al (2015). Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 32-year-old female enrollee has requested reimbursement for prenatal testing performed on 1/10/14. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees suspected fetal abnormality. The physician reviewer found in this case, the prenatal cell-free DNA screening provided on 1/10/14 was likely to be more beneficial than other modalities. The patients 18-week ultrasound revealed two soft markers associated with an increased risk of aneuploidy. The American College of Obstetricians and Gynecologists Committee on Genetics recommend women regardless of maternal age be offered cell-free DNA who present with ultrasonographic findings indicating an increased risk of aneuploidy. This patient presented with ultrasound markers associated with an increased risk of aneuploidy. As such, the testing at issue was likely to be more beneficial than other modalities. 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.