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

Summary Reviewer 


A 49-year-old female enrollee has requested authorization and coverage for breast susceptibility gene (BRCA) testing.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found BRCA mutations are associated with a high incidence of both breast and ovarian cancer. Being BRCA positive has several implications for measures to be considered by the patient.  With regards to breast cancer, she can consider more intense screening with magnetic resonance imaging or even bilateral mastectomies.  With regards to ovarian cancer, it is recommended that such women have bilateral salpingo-oophorectomy at the appropriate age.  Thus BRCA is a genetic test of great potential importance and value.  However, there is a lack of support for the requested services in this patients case.  U.S. Preventative Services Task Force indicates that testing is recommended for women who have a family history including three or more first-degree or second-degree relatives with breast cancer, regardless of age of their diagnosis.  Additionally, there is support for BRCA testing for patients who have a close relative diagnosed with breast cancer under the age of 50.  None of these criteria appear to apply to this patient.  All told, the requested breast susceptibility gene (BRCA) testing is not medically indicated for the evaluation of this patient.  Therefore, the requested services are not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 21-year-old female who sustained a traumatic nasal injury playing soccer on 10/02/17 when she was hit in the nose by a studentas hand. The school nurse reported a nosebleed with the nose slightly swollen. The physician reviewer found that Friedman and colleagues stated, aUnderstanding nasal anatomy and physiology are the most important points for successful functional rhinoplasty. Anatomic structures playing major roles in nasal breathing functions include the septum, and internal and external nasal valves, so physical examination of these regions is essential. Planning for functional rhinoplasty involves the
identification of the sites of nasal airway obstruction or old trauma and addressing those regions during the operation with a number of different techniques that have been described.a Physical examination 7/17/20 reported, aThe nasal dorsum continues to be crooked with the tip of the nose pointing to the left sideaWe would recommend a septoplasty as well as consideration for an open reduction of her nasal fracture since the way the fracture has healed, it appears that the dorsum pointing to the left is pulling the anterior portion of the nasal septum to the left as well, creating a rightward deviation of the nasal septum interfering with the nasal airway.a
A photograph dated 10/11/17, nine days after injury, shows right-sided deviation of the nose and nasal bones. An undated photograph shows a reverse C-deformity of the nose with a deviation of the nasal bones to the left, and a compensatory deviation of the nasal tip to the right. The patient underwent authorized septoplasty for relief of breathing obstruction. Photographs were received for review documenting that the nasal deviation was functionally significant. Narrowing of the nasal valve is evident on the left side. The medical history received for review documents the medical necessity of the rhinoplasty in addition to the authorized septoplasty. Based on the medical history received for review, rhinoplasty was medically necessary. Therefore, CPT 30400 performed on 9/16/20 was medically necessary for the treatment of this patient.
The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function or (2) to create a normal appearance, to the extent possible. Per the submitted documentation, the patientas condition constituted an abnormal structure of the body. This abnormal structure of the body was caused by trauma. The surgery was performed to improve function. Therefore, the California reconstructive surgery statute does apply to the patient. Thus, CPT 30400 performed on 9/16/20 was reconstructive in nature.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 26-year-old male enrollee has requested authorization and coverage for Ocrevus injections 300/10 mL. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for treatment of the enrollees relapsing-remitting multiple sclerosis. The physician reviewer found the submitted documentation supports the medical necessity of the requested medication. The Health Insurer has offered glatiramer acetate and fingolimod (Gilenya) as alternatives. However, this patient has reportedly failed a trial of glatiramer acetate. The records document that the patient tested positive for JC virus. Medications such as Gilenya and Tysabri are contraindicated for patients with positive JC virus titers. There is greater potential for risk of progressive multifocal leukoencephalopathy, an often opportunistic infection from JC virus, in patients treated with Gilenya. The current medical evidence supports the requested medication in this patients case. All told, Ocrevus injections 300/10 mL are medically necessary 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.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 64-year-old female enrollee has requested reimbursement and prospective authorization and coverage for inpatient skilled nursing facility care from 2/16/16 forward.  The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  On 2/14/16 and 2/15/16, she was requiring extensive assistance for her self-care.  She was not ambulating.  She had plateaued at requiring about moderate assistance for her transfers.  There is no documentation of any further, significant progress.  Overall, the patient had health issues and impairments which significantly increased the energy cost of her gait.  These deficits severely limited her functional progress with respect to self-care, transfers and ambulation.  Further rehabilitative care as of 2/16/16 and forward could have been provided at a less intensive level of care such as a custodial facility, or home care with custodial level assistance and community-based rehabilitation.  Given the patients substantial and chronic impairments and the limited gains achieved to date as of 2/16/16, it would not have been anticipated that she would have made further significant functional gains in a predictable and reasonable timeframe.  All told, inpatient skilled nursing facility care from 2/16/16 forward was not and is not medically indicated for the treatment of this patient.  Therefore, the services at issue were not and 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 62-year-old male enrollee has requested reimbursement for the mobile heart monitor provided on 8/2/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees palpitations. The physician reviewer found that the largest multicenter controlled trial to date using real time CardioNet event monitoring included 266 patients with persistent symptoms who had previously undergone prior Holter monitoring which failed to diagnose an arrhythmia (Rothman, et al). Another retrospective analysis of 100 consecutive patients who were undergoing treatment for known arrhythmias using real time monitoring devices showed that a number of treatment changes were made based on findings from the real time monitors, but there was no follow-up to determine whether patient outcomes were improved as a result of this new information (Joshi, et al). Other studies have shown benefit with regard to the diagnostic yield of finding arrhythmias requiring treatment using mobile telemetry event recorders over traditional Holters or event monitors (Olson, et al; Kadish, et al). Given the published data suggesting a higher diagnostic yield of the real time monitored device, along with a higher pre-test probability of an atrial rhythm disturbance, the use of mobile telemetry recording was reasonable. It ultimately also provided clinical information which resulted in diagnosis of the condition, and since the clinical symptoms in the patient diary correlated with the mild rhythm disturbances noted, the data supported a definitive diagnosis. Accordingly, the mobile heart monitor provided on 8/2/17 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 service 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 62-year-old male enrollee has requested reimbursement for the mobile heart monitor provided on 8/2/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees palpitations. The physician reviewer found that he use of different types of ambulatory electrocardiogram monitoring for arrhythmias has evolved over the past 10-15 years (Crawford, et al). Newer patch based systems for two weeks and mobile outpatient telemetry for longer times have developed and are recommended for infrequent symptoms as in this clinical setting. The Heart Rhythm Society noted that the choice of monitor needs to be matched to the individual patients symptom frequency (Steinberg, et al). If symptoms are not present daily, then longer duration monitors are recommended. Given these findings, the mobile heart monitor provided on 8/2/17 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 service 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 62-year-old male enrollee has requested reimbursement for the mobile heart monitor provided on 8/2/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees palpitations. The physician reviewer found that based on the records provided the patient presented with near daily palpitations. In this circumstance, if additional evaluation for a dysrhythmia is thought to be indicated then serial 48-hour Holter monitoring or off-line self-activated or auto-triggered cardiac event monitoring should be sufficient in recording cardiac rhythm during symptoms. There is a lack of documentation to indicate that these devices have already been tried and failed for evaluation of the patients current symptoms. Current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and/or patient-activated or auto-triggered event recorders appropriate initial tests and standard of care for evaluation of dysrhythmias. Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry services has not been shown to improve health outcome compared to standard monitoring techniques. For these reasons, the mobile heart monitor provided on 8/2/17 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 service 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 Overturned

Summary Reviewer 

The patient is a 62-year-old female with a history of mild bilateral carotid artery atherosclerosis, hyperlipidemia and hypertension.The patient has requested authorization and coverage for Repatha. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that the patient has prior evidence of established atherosclerotic vascular disease of the carotid arteries. She has hypertension and hyperlipidemia with a baseline LDL of 166. She is at risk for progression of her peripheral vascular disease and also development of coronary artery disease based on her age and risk factors. She was intolerant of four different statin medications and ezetimibe, which all had to be discontinued. She has had an excellent response to PCSK-9 therapy with Repatha, which has decreased her LDL to her goal without further side effects. Based on her known carotid artery disease, additional risk factors for coronary artery disease and intolerance of multiple statin therapies, PCSK-9 inhibitor therapy with Repatha is medically indicated. Therefore, Repatha is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 56-year-old female enrollee has requested reimbursement for gene test (Breast Cancer Index) performed on 1/6/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who had a history of breast cancer. The physician reviewer found that patients with early stage disease typically undergo primary surgery (lumpectomy or mastectomy) to the affected breast and regional lymph nodes with or without radiation therapy. Adjuvant therapy may be offered based on primary tumor characteristics which include: tumor size, grade, number of involved lymph nodes, the status of the hormone receptors and expression of the HER2 receptor. The Breast Cancer Index (BCI) test is a validated test that can predict the likelihood of benefit from extended endocrine therapy; prognostic for the risk of late distant recurrence in N0 and N1 patients. It is a test intended for use in patient diagnosed with estrogen receptor positive, lymph node negative or lymph node positive (1 to 3) early stage invasive breast cancer. The published studies validating or evaluating the use of the BCI resulted in a change in treatment plan in 26% of cases in which endocrine therapy was being considered. Based on National Comprehensive Cancer Network guidelines, patients with tumor characteristics as demonstrated by this patient, T2N0 ER/PR positive and HER2 negative, invasive breast cancer, 21 gene reverse transcription polymerase chain reaction (RT-PCR) testing should be conducted. The risk of recurrence score should guide the use of adjuvant endocrine therapy and/or chemotherapy. Although the Breast Cancer Index test has been validated, it is not considered in the current standard guidelines. The studies available indicate that it has similar ability to detect low and high risk of recurrence and that it has resulted in a change in clinical practice. However, there is a lack of long term follow up data of its use in this clinical setting. As such, the services at issue were not likely to be more effective than the standard options available for evaluation of this patients medical condition.  
Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 56-year-old female enrollee has requested reimbursement for gene test (Breast Cancer Index) performed on 1/6/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who had a history of breast cancer. The physician reviewer found that the Breast Cancer Index (BCI) is a genome wide microarray analysis developed to identify patients with ER positive breast cancer on endocrine therapy that are at an increased risk of progression. Compared with clinical prognostic factors such as age, tumor size, tumor grade, and lymph node status, the BCI is significantly and independently correlated with outcome. Subsequent studies have validated the BCI as an accurate predictor of endocrine responsiveness among patients with ER-positive breast cancer and of prognosis. In one study, BCI was useful in predicting late recurrence (greater than five years from diagnosis) as compared with other prognostic markers. Given the emerging role of extended adjuvant therapy and the side effects many women experience on them, efforts to identify those patients who are more likely to benefit from this therapy is of great potential value. Therefore, the gene test (Breast Cancer Index) performed on 1/6/17, was more likely to have been of greater benefit than the available standard of care for the 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 Upheld

Summary Reviewer 3

A 56-year-old female enrollee has requested reimbursement for gene test (Breast Cancer Index) performed on 1/6/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who had a history of breast cancer. The physician reviewer found that the Breast Cancer Index test was investigational for the evaluation of this patient. Randomized prospective clinical trials showing progression free survival or overall survival benefit using this test are lacking. As such, recommending this test remains provocative and debatable. The results from the test showed very low risk for recurrence. The adjuvant hormonal therapy was based on stage at diagnosis and hormonal status. Accordingly, the gene test (Breast Cancer Index) performed on 1/6/17 was not likely to have been superior over the other methods of evaluating this patients medical condition.  
Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 52-year-old female enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 7/7/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees colonic Crohns disease. The physician reviewer found the Prometheus Anser IFX diagnostic testing performed on 7/7/14 was likely to be more effective for this patient than other available treatment options. The patient was complaining of body aches and fatigue and had been evaluated by rheumatology which was negative. Thus, her treating provider ordered testing to check for adalimumab levels and antibodies to adalimumab. The dose interval subsequently decreased to every three weeks. Therefore, Prometheus Anser IFX testing was appropriate for the management of the patients Crohns disease in order to optimize her therapy and to maintain remission without drug toxicity. 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 52-year-old female enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 7/7/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees colonic Crohns disease. The physician reviewer found the Prometheus Anser IFX diagnostic testing performed on 7/7/14 was not likely to be more effective for this patient than other available treatment options. Menting and colleagues noted that patients with no [antidrug antibody] ADA formation in the first 24 weeks of treatment have little chance of it in the following 24 weeks. The presence of ADA is strongly correlated with adalimumab concentration. In this case, there is documentation of benefit from her use of adalimumab. In such a scenario, the clinical utility is unclear for testing of adalimumab levels. As such, it cannot be concluded that the Prometheus Anser IFX testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy such as adjusting therapy based on available clinical data and observation. 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 Overturned

Summary Reviewer 3


A 52-year-old female enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 7/7/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees colonic Crohns disease. The physician reviewer found the testing at issue was likely to be more effective for this patient than other available treatment options. The patient presents with inflammatory bowel disease (IBD), namely Crohns disease. The Prometheus Anser IFX test measures the Humira blood level and detects antibodies to Humira. The clinical indication for testing was to ensure adequate levels, lack of antibodies and to determine whether her symptoms were likely related to Crohns disease versus an alternate diagnosis. Due to the multitude of management options once a patient loses response to Humira or has unexplained episodic symptoms that could be attributed to disease flares and the fact that these medications have 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. The Prometheus Anser IFX test provides such a roadmap and was likely to be more beneficial for evaluation and treatment of the patients Crohns disease than other modalities. 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.