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

Summary Reviewer 1

A 53-year-old female enrollee has requested reimbursement for gene testing performed to gauge risk for thyroid cancer on 2/16/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees follicular lesion of undetermined significance.  The physician reviewer found that while a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate (Alexander, et al). Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign (Miller, et al). The Afirma Thyroid FNA Analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures (Duick, et al). For these reasons, the gene testing performed to gauge risk for thyroid cancer on 2/16/17 was 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 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 Overturned

Summary Reviewer 2

[INSERT FIRST TWO SENTENCES FROM SUMMARY REVIEW DETERMINATION] The physician reviewer found that according to the documentation submitted for review, the patient underwent FNA of three thyroid nodules and the cytopathology of the right dominant nodule was interpreted as AUS with Afirma testing interpreted as benign. The clinical documentation does not demonstrate that a repeat FNA was performed at the time the initial cytopathology came back as AUS. Due to the lack of clinical documentation demonstrating a repeat FNA was performed, the gene testing performed to gauge risk for thyroid cancer on 2/16/17 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 Overturned

Summary Reviewer 3

[INSERT FIRST TWO SENTENCES FROM SUMMARY REVIEW DETERMINATION] The physician reviewer found that the gene testing performed to gauge risk for thyroid cancer on 2/16/17 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Cytopathology of the 1.9 cm thyroid nodule was consistent with AUS. The risk of malignancy is 5-15% in AUS (Cibas, et al; Haugen, et al). The risk of malignancy decreases to less than 6% with benign findings by gene expression classifier (Haugen, et al; Alexander, et al). In this case, the patients thyroid nodule was enlarged with suspicious features, such as size, it is hypoechoic and has intranodal vascularity. It is one among other nodules, which had not enlarged significantly. In this clinical setting gene testing was appropriate to determine whether to perform a diagnostic hemithyroidectomy or an oncological thyroidectomy, if the result were suspicious. Therefore, the testing at issue has been established as 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 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 Overturned

Summary Reviewer 1


A 53-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 3/11/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees risk for breast cancer.   The physician reviewer found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis performed on 3/11/16 was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Based upon the information set forth above, the diagnostic procedure 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.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 53-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 3/11/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees risk for breast cancer.   The physician reviewer found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed on 3/11/16 was 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 diagnostic procedure 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.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 53-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 3/11/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees risk for breast cancer.   The physician reviewer found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. However, in this particular patient, there were no problems to be resolved, the patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. Thus, a routine mammogram would have been sufficient for evaluation of the patients risk for breast cancer. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to prior mammograms. Given these findings, the breast tomosynthesis performed on 3/11/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard imaging technique.  Based upon the information set forth above, the diagnostic procedure 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 19-year-old male enrollee has requested reimbursement for residential treatment center (RTC) substance use disorder treatment services provided from 2/9/16 through 4/25/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees depression and cannabis related disorder. The physician reviewer found that based on the records provided for review, the RTC substance use disorder treatment services provided from 2/9/16 through 4/25/16 were not medically necessary. The patient was cooperative in treatment and could have been safely and adequately treated in a less restrictive setting. The progress notes from the disputed period indicate that the patient was cooperative in treatment and open to therapy. The patient did not express suicidal ideation or severe mood lability during the disputed period. Moreover, the patient did not have any self-harm behaviors, was medically stable, and did not demonstrate any withdrawal symptoms. As RTC services are considered the highest level of psychiatric care available, medical necessity guidelines and evidence-based practice indicate that a patients psychiatric symptoms must be severe and present to the degree that this level of care is needed. Applying the Level of Care Utilization System (LOCUS), this patient was a candidate for low intensity community based services. The patient was a low risk of harm, his functional status was mild, and he had no medical instability or severe psychiatric issues. In addition, the patient had a stable living and recovery environment, and was cooperative in treatment and provided insight into the need for treatment. Similarly, according to the American Society of Addiction Medicine (ASAM), the patient had mild emotional/behavioral or cognitive conditions and complications that were stable, had minimal motivation, and has a risk for relapse due to a minimal period of sobriety, amenable to treatment with intensive outpatient services, nine or more hours of service per week. Given these findings, the RTC substance use disorder treatment services provided from 2/9/16 through 4/25/16 were not medically necessary for treatment of this patients medical condition. Based on these findings, 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 61-year-old male enrollee has requested authorization and coverage for positron emission tomography (PET) scan. The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the current medical evidence supports the requested services in this clinical setting.  Damle and colleagues noted that 18-F-fluoride positron emission tomography/computed tomography (PET/CT) is the most reliable method to rule out bone metastases in cases where there is a high index of suspicion.  The authors noted that PET/CT has the potential to replace the (99m) Tc-MDP bone scan for the detection of bone metastases.  In sum, the requested PET scan is likely to be of greater benefit than other modalities for evaluating this patient.  Based upon the information set forth above, the requested services are 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 Overturned

Summary Reviewer 2


A 61-year-old male enrollee has requested authorization and coverage for positron emission tomography (PET) scan. The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the patient has a rapidly rising prostate-specific antigen level after radical prostatectomy, and there were inconsistencies on imaging.  It has been extensively shown that sodium fluoride positron emission tomography/computed tomography (PET/CT) is a sensitive means with which to detect boney metastases, and this modality would provide the best assessment for the extent of metastatic disease.  As the most sensitive bone scanning agent available, this requested technique would be the best way to analyze the equivocal findings.  In sum, the requested PET scan is likely to be superior over other methods of evaluating this patient.  Based upon the information set forth above, the requested services are 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 Overturned

Summary Reviewer 3


A 61-year-old male enrollee has requested authorization and coverage for positron emission tomography (PET) scan. The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found following the diagnosis and initial treatment for prostate cancer, it is conventional to obtain sequential prostate-specific antigen levels every six to twelve months for five years.  With a failure of the prostate-specific antigen levels to fall to undetectable levels, or with progressive increases in prostate-specific antigen levels, it is then common to further evaluate the patient with imaging possibly further biopsies.  These additional studies will generally dictate future treatment options.  For the most part, conventional bone scans will suffice.  However, routine bone scans will occasionally not be diagnostic and scanning with sodium fluoride positron emission tomography/computed tomography (PET/CT) scans has been developed as a second-line scanning technique.  In this patients case, the records indicate that the therapy will be dramatically altered depending on the results of the requested PET scan.  If the metastatic disease is limited to a small anatomic region, this can be controlled with focal radiation.  If the disease is more anatomically widespread, then he will undergo more aggressive therapy.  In sum, the requested PET scan is likely to be more effective than other methods of evaluating this patient.  Based upon the information set forth above, the requested services are 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

The patient is a 55-year-old male who fell down a flight of stairs on 3/10/18, injuring his left shoulder, left hip, and lower back. He was evaluated in urgent care the next day. There was limitation of motion and pain in the left shoulder. X-rays did not reveal any fractures. Evaluation by primary care provider on 3/16/18 revealed limited motion and pain in the shoulder. Orthopedic referral and magnetic resonance imaging (MRI) scan was advised to rule out a rotator cuff tear. An orthopedic surgeon concurred with the recommendation for an MRI scan of the shoulder. The Plan denied the request for shoulder MRI as four weeks of stretching exercises had not been documented. The patient has requested authorization and coverage for MRI scan because of the acute injury, limitation of range of motion and continuing pain to rule out a rotator cuff tear. The Health Insurer has denied this request indicating that the requested services are not medically necessary for the evaluation of the patient. This denial is the subject of this appeal and determination. The patient has sustained significant acute trauma to the left shoulder as a result of a fall down a flight of stairs. X-rays have been negative for fractures. However, the pain and limitation of motion persists. Traumatic pain may result from a fracture or soft tissue injury, most commonly to the rotator cuff. Imaging starts with x-rays and depending on physical examination findings, as next steps, an MRI or MR arthrography for assessment of soft tissue injuries may be required. In light of the persisting pain, a month after the injury, the MRI is appropriate according to American College of Radiology appropriateness Criteria (Amini, et al). The nature of the acute trauma, continuing pain, and the physical examination findings are considered to establish an accurate diagnosis in a timely fashion and achieve an optimal result from any surgical intervention that may be necessary in an active individual. A more aggressive management and diagnostic strategy may identify those in need of early operative intervention and provide robust rehabilitation programs. As such, in this patients case the requested MRI scan has been demonstrated as medically necessary for the evaluation of this patients medical condition. Therefore, based on the reasons stated above, the requested services are medically necessary for the evaluation of this patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 56-year-old male enrollee has requested reimbursement for DecisionDx Melanoma testing performed on 11/14/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has been thought to add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami reported on 217 cases, with good correlation between DecisionDx-Melanoma testing class and prognosis in patients undergoing sentinel node biopsy. Berger reported on 156 cases, but there was not sufficient follow-up to determine the real value of the assay. It is not clear how the five-year DecisionDx-Melanoma testing date compares to the ten-year Balch data. Most importantly, it is unknown if it can be used to make clinical decisions. Therefore, DecisionDx-Melanoma testing performed on 11/14/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 56-year-old male enrollee has requested reimbursement for DecisionDx Melanoma testing performed on 11/14/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines states while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. This test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. In sum, DecisionDx-Melanoma testing performed on 11/14/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 56-year-old male enrollee has requested reimbursement for DecisionDx Melanoma testing performed on 11/14/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that melanoma is a cancer that is curable in its earliest stages. 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 this suggests 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 DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing performed on 11/14/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 73-year-old male requested reimbursement for genetic testing performed on 9/26/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma.  The physician reviewer found that the patient is a 73-year-old male status post heart and kidney transplant, diagnosed with recurrent squamous cell carcinoma of the skin of the scalp. He apparently had prior squamous cell carcinoma of scalp treated with radiation and Mohs surgery. In July 2016, he had recurrent cancer on his scalp, proven by biopsy. His tissue was sent for FoundationOne assay. The patient requested reimbursement for genetic testing performed on 9/26/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational.FoundationOne is a molecular assay that explores the mutations of an individual patients cancer cells. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the FoundationOne assay adds to decision making ability, or yields a result that is reliably clinically beneficial. There are non-randomized studies exploring the value of molecular profiling, but the results have not been convincing as to the efficacy of such an approach to treatment (Von Hoff, et al). A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment (LeTourneau, et al). Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. All told, the FoundationOne test provided on 9/26/16 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 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.