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

Summary Reviewer 3


A 62-year-old male enrollee has requested reimbursement for the RT300 functional electrical stimulator (FES) cycle provided on 2/10/16. The Health Insurer has denied this request indicating that the equipment at issue was considered investigational for treatment of the enrollees quadriplegia.   The physician reviewer found the RT300 FES is a primary at-home internet linked and remote-clinician monitored intervention for patients with spinal cord injury (SCI) that provides intense electrical stimulation to intact peripheral nerves below the level of the SCI to evoke muscle contractions. Physical activities, like FES, that provide adequate stress to bone, can play a role in the improvement in bone mineral density with the possible prevention or reduction of osteoporosis and a decrease in fractures, two disabling and costly conditions for persons with paralysis due to SCI (Dolbow, et al). In addition, Fazio noted that repeated use of FES can lead to sensorimotor improvements as well as cortical reorganization, changes that cannot be accomplished with passive range of motion alone due to lack of sensory or motor input or activation of motor units, which is essential for motor relearning and neuromuscular reeducation. Thus, the intended in-home use of the RT300 FES cycle will help to remove many of the physical barriers to exercise which is a key factor in promoting regular physical activity in the SCI patient. For these reasons, the RT300 FES cycle provided on 2/10/16 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 equipment 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 Upheld

Summary Reviewer 1

A 63-year-old female has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees pain. The physician reviewer found that this patient presented with persistent and worsening low back pain radiating into the bilateral lower extremities, and severe sacroiliac joint pain. She was status post anterior and posterior lumbar fusion from L3 through the sacrum. She had recently been involved in a motor vehicle accident with elevation of symptoms. There is imaging evidence of facet and disc pathology at the adjacent L2-3 level. Surgery has been requested to include L2-3 decompression and interbody fusion with fusion from L2 to the pelvis, including the sacroiliac joints. Inclusion of the sacroiliac joints into the surgical construct would typically be supported upon documentation of pain generation relative to the sacroiliac joints. However, there is no documentation of physical examination indicators of pain relative to sacroiliac joint pathology, including three positive provocative tests. There is no documentation of radiographic evidence of spondyloarthropathy. There is no documentation of at least 75% pain reduction following a diagnostic intraarticular sacroiliac joint injection. Therefore, the requested sacroiliac joint fusion is not likely to be of greater benefit than other available 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 63-year-old female has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees pain. The physician reviewer found that there is a lack of support for the requested services in this clinical setting. This patient has a history of prior lumbar spine fusion from L3 to the sacrum. According to the records, she has low back pain, buttock pain and radicular symptoms.  She reportedly had a positive response to a diagnostic sacroiliac injection, but the laterality of the procedure and the pain relief from the procedure are not documented.  The literature does not support the efficacy of sacroiliac joint fusion for the treatment of low back pain and buttock pain with high quality evidence.  In this case, the requested sacroiliac joint fusion is not likely to be more efficacious than other treatment alternatives. 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 63-year-old female has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees pain. The physician reviewer found that in the article by Polly and colleagues, a randomized controlled trial of minimally invasive sacroiliac joint fusion using triangular titanium implants was compared to nonsurgical treatment at 12 months. A total of 148 patients with sacroiliac joint dysfunction were randomly assigned to minimally invasive sacroiliac joint fusion with triangular titanium implants or nonsurgical treatment.  The conclusion was that this level one study showed that minimally invasive sacroiliac joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with sacroiliac joint dysfunction caused by degenerative sacroiliitis or sacroiliac joint disruptions.  Pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment.  In the article by Whang and colleague, sacroiliac joint fusion using triangular titanium implants was compared to nonsurgical management at six months with a prospective randomized controlled trial.  The authors noted that minimally invasive sacroiliac joint fusion using triangular titanium implants was more effective than nonsurgical management in relieving pain, improving function, and improving quality of life in patients with sacroiliac joint dysfunction due to degenerative sacroiliitis or sacroiliac joint disruptions. Thus, the requested sacroiliac joint fusion is likely to be of greater benefit than other treatment options.  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 Upheld

Summary Reviewer 


A 61-year-old male enrollee has requested authorization and coverage for 100 mcg 15 fentanyl patches per month and 10 mg methadone. The Health Insurer has denied this request indicating that the requested medication dosages are not medically necessary for treatment of the enrollees chronic pain. The physician reviewer found that the dose escalation is not a long term plan but a short term plan for the treatment of tolerance. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in this case, there is no medical evidence based rationale given for the increase in dosage by the provider. Not all non-opioid treatment options have been utilized. The records do not mention the completion of behavior therapy despite much research to support its use. In addition, the medical literature indicates that in this clinical setting, it is also reasonable to consider alternatives to opioids and to wean the patient to a lower dose of opioids or even off opioids. Furthermore, no objective treatment goals for pain and function are noted for the requested medication. Also, several requirements for opioid prescribing have not been documented and the need to use them as the primary medication treatment strategy for pain has not been established. The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, clinicians should prescribe immediate release opioids instead of extended release/long acting (ER/LA) opioids. The CDC also states when opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to = 50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to = 90 MME/day or carefully justify a decision to titrate dosage to = 90 MME/day. In this case, the patient was recently taking 840 MME/day. No medical evidence based rationale is given by the provider or the patient, for the long term consequences with the continual increase in opioids. Risk and benefit analysis must be performed to justify the requested level of 840 MME/day. The submitted documentation is unclear as to what the plan is for any unseen future pain insults the patient would experience while on 840 MME/day. Dose escalation is not a long term plan. The provider has not provided clear objective goals with this high of a dose for these requested medications.  As noted above, not all non-opioid medications classes have been optimized or tried. For all these reasons, 100 mcg 15 fentanyl patches per month and 10 mg methadone are not medically necessary for treatment of the patients medical condition. Therefore, for the reasons stated above, the requested medication dosages are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The patient is a 65-year-old male with a history of prostate cancer. The patient was initially diagnosed in 2015.  The provider noted that despite an initial excellent response to six cycles of docetaxel chemotherapy, the patients prostate specific antigen (PSA) levels rose. The provider recommended treatment with Cabometyx. The patient has requested authorization and coverage for Cabometyx (cabozantinib) 60 mg #30/30. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of this patients medical condition. The use of cabozantinib for prostate cancer is not U.S Food and Drug Administration approved and is not supported by major drug compendia for off-label use. A phase III clinical trial, COMET-1, has not shown a benefit in overall survival. Another phase III trial combining cabozantinib with mitoxantrone was discontinued after the results of COMET-1. The use of molecular profiling to match molecular mutations with clinical trials is still ongoing. Therefore, Cabometyx (cabozantinib) 60 mg #30/30 is not likely to be more beneficial for treatment of this patients medical condition than the available standard therapy. Based upon the information set forth above, the requested medication is 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

The patient is a 65-year-old male who has been diagnosed with prostate cancer. The records noted that he has castrate resistant prostate cancer status post systemic therapy using docetaxel, followed by enzalutamide and cabazitaxel. The disease has now progressed and the treating provider ordered a Guardant360 molecular test, which identified a MET proto-oncogene mutation. The treating provider stated that there are preclinical models suggesting that MET proto-oncogene mutations are a good target for cabozantinib. The patient has requested authorization and coverage for Cabometyx (cabozantinib) 60 mg #30/30. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of this patients medical condition. There is a lack of peer reviewed literature to support the requested medication in this clinical setting. As stated by the treating provider, there are preclinical models for potential activity in MET mutations. As such, the use of this therapy, outside of a well conducted clinical trial, is potentially harmful and may not generate meaningful conclusions. In sum, Cabometyx (cabozantinib) 60 mg #30/30 is not likely to be more effective than the available options for treatment of this patients medical condition. Based upon the information set forth above, the requested medication is 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

The patient is a 65-year-old male who was diagnosed in March 2015 with prostate cancer. At that time, he was found to have bone metastases. He was initially treated with radiation therapy, androgen deprivation therapy, and docetaxel, then enzalutamide. With progression, he was treated with cabazitaxel, but there was no response with this therapy. The provider had recommended cabozantinib for treatment. The patient has requested authorization and coverage for Cabometyx (cabozantinib) 60 mg #30/30. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of this patients medical condition.  Cabozantinib is a tyrosine kinase inhibitor that has been approved for use in renal cell carcinoma but not prostate cancer. This therapy with cabozantinib is not within National Cancer Comprehensive Network guidelines for treatment of prostate cancer. This patients provider proposed using it in this patient based on some very early phase studies in prostate cancer as well as a theoretical belief that it might be useful in those patients with a MET mutation, which this patient has. However, there is limited data that confirms clinical benefit in the use of this therapy for patients who are diagnosed with prostate cancer. The provider had also noted the lack of clinical benefit from these early studies.  Furthermore, the presence of the MET mutation is not an indication that there is a reasonable likelihood of response to cabozantinib. Accordingly, at this time, cabozantinib is not likely to be of greater clinical benefit for the treatment of this patient than any other standard form of therapy.  Based upon the information set forth above, the requested medication is 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 1

A 30-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 6/16/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the Prometheus Anser IFX diagnostic testing performed on 6/16/14 was not likely to be more effective for this patient than other available treatment options. There is a lack of controlled data supporting the testing for antibodies or adalimumab levels in this clinical setting. The patient demonstrated a clinical and radiographic improvement and was tolerating therapy without problems. There were no infusion reactions or other indications of the development of human anti-chimeric antibodies. Given the lack of support in the peer-reviewed literature, the testing at issue was not likely to be more beneficial than other modalities. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 30-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 6/16/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the Prometheus Anser ADA test is a quantitative measurement of serum adalimumab and anti-ADA antibodies. There are few well controlled clinical trials to confirm that use of the Anser ADA test leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al). Moreover, it has not been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established, such as in this case. For the reasons provided, the Prometheus Anser ADA diagnostic testing performed on 6/16/14 was not more beneficial for treatment of the patients medical condition than conventional treatment strategies. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 30-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 6/16/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees Crohns disease. The physician reviewer found in this case, the patient has Crohns disease and was started on Remicade in February 2014. Several months post Remicade treatment he had recurrent symptoms of diarrhea despite adequate response initially on Remicade. Due to the multitude of management options once a patient has no response to Remicade and the fact that Remicade has a wide array of adverse effects, it is important for the treating provider to have a roadmap of the nature of the patients clinical course. ADA testing provides important and significant management implications, and was clinically indicated in this case. Based upon the information set forth above, the testing 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 Overturned

Summary Reviewer 

The parent of a five-year-old female enrollee has requested authorization and coverage for therapeutic activities, direct (one on one) patient contact. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient has documented difficulties with motor coordination, postural stability, self-regulation, and fine/gross motor skills. With its focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills, processing information, and regulating the response to incoming information, occupational therapy is an appropriate intervention strategy for this patient. Sensory-based interventions alone have not been demonstrated to be beneficial. However, it may be acceptable to incorporate sensory-based modalities into a comprehensive treatment plan. This patient has challenges that negatively impact her daily functioning, and occupational therapy is appropriate to address these challenges. The submitted documentation supports the requested services in this clinical setting. Therefore, therapeutic activities, direct (one-on-one) patient contact are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The patient is a 61-year-old female with a history of attention deficit hyperactivity disorder (ADHD) and malabsorption syndrome status post Roux-en-Y gastrojejunostomy in 2003. A letter from the patients provider indicates that she has a history of binge eating disorder. Per the provider, the patient has been stable on Vyvanse 70 mg three times per day since 9/3/12. The patient has requested authorization and coverage for Vyvanse 70 mg three times a day (TID). The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational. 
Treatment guidelines or ADHD for adults indicate that a failure of stimulant medications should be followed by a trial of treatment with alternative medication such as atomoxetine or bupropion. This patients records do not include documentation of trial and failure of non-stimulant type medications. Moreover, the current treatment guidelines do not support the safety of the requested medication dosage. The literature does not support the use of Vyvanse above the FDA recommend maximum of 70 mg per day. All told, the requested Vyvanse 70 mg TID is not supported as medically necessary for treatment of this patients medical condition.  Based upon the information set forth above, the requested medication dosage is 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

The patient is a 61-year-old female diagnosed with attention deficit hyperactivity disorder (ADHD), binge eating disorder and malabsorption syndrome status-post gastric bypass surgery. The patient had reportedly been on lisdexamfetamine (Vyvanse) since 2012. In 2017, it appears that medication became less effective, lasting no more than four hours. On Vyvanse 70 mg three times a day (TID), the dose was well tolerated, with no insomnia or other side effects. The patient has requested authorization and coverage for Vyvanse 70 mg TID. The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational. 
Stimulant medications, like Vyvanse, are first-line therapies for ADHD. This patients records document that she has been diagnosed with ADHD and binge eating disorder. The current dose of Vyvanse was achieved after a systematic reasonable titration due to her comorbid conditions. The decreased bioavailability and lowered absorption of orally administered drugs in this clinical setting is common due to the bypassing of the duodenum, proximal jejunum and majority of the stomach. The medication dose appears to be both efficacious and well-tolerated, with no evidence that it is unsafe. The medication is approved by the FDA for the conditions being treated. The treatment is optimizing functionality and minimizing the patients illness burden. It is the recommendation of the treating provider to continue the medication at the current dose. The patient desires to continue the treatment. Considering all aspects of this patients case, the requested Vyvanse 70 mg TID is 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 medication dosage is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.