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

Summary Reviewer 1

A 46-year-old female enrollee has requested reimbursement for Afirma Gene Expression Classifier testing performed on 9/6/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees thyroid nodule. 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 Gene Expression Classifier 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 Afirma Gene Expression Classifier testing performed on 9/6/16 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 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

A 46-year-old female enrollee has requested reimbursement for Afirma Gene Expression Classifier testing performed on 9/6/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees thyroid nodule. The physician reviewer found that according to Alexander and colleagues Patients with cytologically indeterminate nodules are often referred for diagnostic surgery, though most of these nodules prove to be benign. Gene expression classifiers better distinguish benign from malignant thyroid nodules. In this case, the patients initial cytology was indeterminate for surgery and the Afirma genetic test is a useful tool when cytology is indeterminate. Accordingly, the specimen sent for Afirma gene expression classifier performed on 9/6/16 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 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 3

A 46-year-old female enrollee has requested reimbursement for Afirma Gene Expression Classifier testing performed on 9/6/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees thyroid nodule.The physician reviewer found the American Thyroid Associations guidelines state that for follicular neoplasm nodules, molecular testing may be used to supplement malignancy risk assessment data in lieu of proceeding directly with surgery. In this case, the cytopathology of the 3.4 cm thyroid nodule was consistent with a follicular neoplasm. The risk of malignancy is 15-30% in follicular neoplasm nodules (Cibas, et al; Haugen, et al). The result of the gene expression classifier was benign, which may prevent unnecessary surgery. In addition, there are multiple peer-reviewed scientific articles supporting the benefit of genetic testing in thyroid nodules (Haugen, et al; Alexander, et al). Therefore, the Afirma Gene Expression Classifier testing performed on 9/6/16 was likely to be more beneficial for the evaluation of the patients medical condition than other 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 57-year-old male enrollee has requested authorization and coverage for itraconazole capsules 100 mg, two (2) twice per day one week per month for three months; 28 capsules every 30 days for three (3) months. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees onychomycosis.  The physician reviewer found that the Itraconazole is covered for patients with diabetes or peripheral vascular disease with a positive fungal culture or for patients who have documented pain with a positive fungal culture. Although the patient is not a diabetic and does not have peripheral vascular disease, there is documentation that the nails are increasingly painful and there is a positive fungal culture which supports an indication for this therapy. Accordingly, the requested itraconazole capsules 100 mg, two (2) twice per day one week per month for three months; 28 capsules every 30 days for three (3) months is medically necessary for the treatment of this patients condition.Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 34-year-old female enrollee has requested reimbursement for genetic testing for fragile X syndrome (CPT code 81423) provided on 6/28/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees pregnancy. The physician reviewer found that SMA is an autosomal recessive disease characterized by degeneration of spinal cord motor neurons that leads to atrophy of skeletal muscle and overall weakness. The disorder is caused by a mutation in the gene known as the survival motor neuron gene (SMN1), which is responsible for the production of a protein essential to motor neuron function. Because of the severity and relatively high carrier frequency, there has been increasing interest in carrier screening for spinal muscular atrophy in the general prenatal population. The American College of Obstetricians and Gynecologists (ACOG) recommends screening for SMA in all women who are considering pregnancy or are currently pregnant. However, fragile X syndrome is the most common inherited form of intellectual disability. Fragile X premutation carrier screening is recommended for women with a family history of fragile X-related disorders or intellectual disability suggestive of fragile X syndrome and who are considering pregnancy or are currently pregnant. However, fragile X testing is not recommended in the absence of family history. For these reasons, the genetic testing for fragile X syndrome (CPT code 81423) provided on 6/28/17 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 Upheld

Summary Reviewer 2

A 34-year-old female enrollee has requested reimbursement for genetic testing for fragile X syndrome (CPT code 81423) provided on 6/28/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees pregnancy. The physician reviewer found that according to the American College of Obstetricians and Gynecologists (ACOG), screening for spinal muscular atrophy should be offered to all women who are considering pregnancy or are currently pregnant. However, the ACOG only recommends fragile X syndrome testing for patients with a family history of fragile X-related disorders or intellectual disability suggestive of fragile X syndrome and who are considering pregnancy or are currently pregnant or if a woman has unexplained ovarian insufficiency or failure or an elevated follicle-stimulating hormone level before age 40 years, fragile X carrier screening is recommended to determine whether she has an FMR1 premutation. In cases of this discordance, the patient should be referred to a genetics professional. However, the ACOG does not support an indication for genetic testing for fragile X syndrome in this clinical setting. For these reasons, the genetic testing for fragile X syndrome (CPT code 81423) provided on 6/28/17 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 Upheld

Summary Reviewer 3

A 34-year-old female enrollee has requested reimbursement for genetic testing for fragile X syndrome (CPT code 81423) provided on 6/28/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees pregnancy. The physician reviewer found that the American College of Obstetricians and Gynecologists (ACOG) recommends that all patients be screened for cystic fibrosis and SMA. However, the ACOG states that fragile X testing is only indicated for patients with a family history of fragile X-related disorders or intellectual disability suggestive of fragile X syndrome and who are considering pregnancy or are currently pregnant or if a woman has unexplained ovarian insufficiency or failure or an elevated follicle-stimulating hormone level before age 40 years, fragile X carrier screening is recommended to determine whether she has an FMR1. Based on these guidelines, the genetic testing for fragile X syndrome (CPT code 81423) provided on 6/28/17 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 Upheld

Summary Reviewer 1


A 38-year-old female has requested reimbursement for laboratory testing performed on 7/06/15.  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 recurrent pregnancy loss. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  The records indicate that the patient had a history of two first trimester miscarriages and had the diagnosis of recurrent miscarriage.  The etiologies for recurrent miscarriage may include chromosomal, uterine structural, ovulatory, thrombophilias and immune factors or combinations of these factors. The obstetric complications most often associated with thrombophilias are miscarriage, stillbirth, and abruption.  The American Society for Reproductive Medicine, in its Practice Committee Opinion, notes that screening for inherited thrombophilias may be appropriate when a patient has a personal history of venous thromboembolism in the setting of a non-recurrent risk factor (such as surgery) or a first-degree relative with a known or suspected high-risk thrombophilia.  There is no evidence in the medical record that the patient has a personal or family history of a thrombophilia. Therefore, there is no support within the standard of care for inherited thrombophilia testing. In addition, the medical evidence indicates that there is no significant association between MTHFR and recurrent miscarriage.  Therefore, MTHFR testing is not within the standard of care.  In sum, laboratory testing performed on 7/06/15 was not likely to have been of greater benefit than 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 38-year-old female has requested reimbursement for laboratory testing performed on 7/06/15.  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 recurrent pregnancy loss. The physician reviewer found the medical evidence does not support the superior effectiveness of the services at issue in this patients case.  This is a situation where there were a number of possible reasons for this patients miscarriages, including her advanced age, her hypothyroidism, and the septate uterus.  In fact, her age and likely a chromosomal issue accounted for the early first trimester loss, and the septum was likely the etiology of the second trimester loss.  As part of her work-up the provider ordered a thrombophilia panel.  The reason put forth was that this might be useful if the assessment for a uterine anomaly did not reveal a problem.  However, current medical literature does not support such screening in a patient with a prior first and second trimester loss, such as in this case.  In sum, the information from the panel was not likely to elucidate the cause of her pregnancy losses, nor would it change her future treatment.  There were other diagnoses that likely contributed to the pregnancy losses.  In sum, laboratory testing performed on 7/06/15 was not likely to have been of greater benefit than 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 3


A 38-year-old female has requested reimbursement for laboratory testing performed on 7/06/15.  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 recurrent pregnancy loss. The physician reviewer found the current medical evidence fails to support the services at issue in this setting.  The records indicate that the patient had a second trimester pregnancy loss.  The likely etiology of this loss would be suggestive of a spontaneous or inherited genetic mutation or a complication of implantation/placental development.  Secondary to other early genetic testing results the patient had Non Invasive Prenatal Screen Testing, the results of which were negative.  Given the patient had studies suggestive of a structural anomaly within the uterus and that she subsequently underwent a septum removal, it is possible that was the underlying etiology.  Per the American College of Obstetricians and Gynecologists, testing for inherited thrombophilias in women who have experienced recurrent fetal loss or placental abruption is not recommended because it is unclear if anticoagulation therapy reduces recurrence.  Although there may be an association in these cases, there is insufficient clinical evidence that antepartum prophylaxis with unfractionated heparin or low molecular weight heparin prevents recurrence in these patients.  The only superseding issue would be if the patient had a personal history of venous thromboembolism or a first-degree relative with a history of high-risk thrombophilia.  No such history appears to be presented in this case.  Thus, laboratory testing performed on 7/06/15 was not likely to have been of greater benefit than 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 13-year-old male with extreme short stature and growth hormone deficiency (GHD). The patients parent has requested authorization and coverage for Norditropin Flexpro 30 mg/3 ml. 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 current medical evidence supports the requested medication in this patients case. His height is severely compromised, and he has been growing poorly. Per the growth chart, the patient has experienced growth failure over several years. The growth velocity is less than the third percentile of normal range. In sum, the patient has demonstrated growth failure, low IGF-1 levels and predicted adult height less than mid-parental height. His presentation is consistent with growth hormone deficiency with a severe delay in bone age. In this setting, growth hormone is a standard of care. Therefore, Norditropin Flexpro 30 mg/3 ml is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 35-year-old female with a diagnosis of rheumatoid arthritis. She has tried and failed Plaquenil, nonsteroidal anti-inflammatory drugs and steroids. The physician reviewer found that the tumor necrosis factor (TNF) inhibitors, such as Cimzia, are a recognized alternative to standard disease-modifying anti-rheumatic drug (DMARD) therapy for patients who fail first-line DMARD therapy, as was the case in this patient. Unfortunately, management of rheumatoid arthritis in pregnancy is fraught with difficult issues as most agents are toxic to developing embryos. The records indicate that the patient has tried and failed Plaquenil, nonsteroidal anti-inflammatory drugs and low dose steroids for the treatment of her rheumatoid arthritis. Additionally, she has not responded adequately to U.S. Food and Drug Administration (FDA) and manufacturer recommended dose of Cimzia. However, there are many other therapies she has not tried and failed. The requested therapy is twice the FDA and manufacturer recommeded doses for the treatment of her condition and has not been proven to be the most safe and effective treatment for this diagnosis. Cimzia is not approved for intended use at requested doses. The provider is concerned because the patient is attempting conception. Although Cimzia is pegolated and intheory does not cross the placenta, it is not recommended in pregnancy by the manufacturer. The medical evidence does not support the requested medication regimen in this clinical setting. Therefore, Cimzia 200 mg injection, four per month is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 57-year-old male with a history of oligometastatic adenocarcinoma of his prostate gland. The patient has requested authorization and coverage for intensity modulated radiation therapy image-guided radiation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the requested services are standard of care in this clinical setting. High-quality clinical outcomes published in the peer-reviewed medical literature have proven that aggressive consolidation of oligometastatic prostate cancer is associated with a significant improvement in chances for long-term survival. The high-quality prospective trial by Parker and colleagues supports such a benefit, as definitive radiotherapy improved failure-free survival. IMRT is widely employed nationwide for similar patients in this setting. Therefore, intensity modulated radiation therapy image-guided radiation is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 22-year-old female enrollee has requested reimbursement for burn wound treatment provided on 1/10/19 (CPT 15273, 15274, 15277 and 15278). The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the medical records support the superior efficacy of a portion of the services at issue. This patient sustained 15% total body surface area second-degree and third-degree burns on the perineum and feet. She was initially managed with dressing changes. The burns developed a thick eschar, and it was felt they were not adequately being managed with dressing changes. On 1/10/19, she underwent debridement of the 15% total body surface area second-degree and third-degree burns of the perineum, bilateral thighs, bilateral lower legs and left foot, including all toes. The debrided burn wounds were then covered with Suprathel skin substitute. Skin substitutes, such as Suprathel, offer the benefit of not requiring a host donor. Based on this benefit, skin substitutes offer benefits over traditional grafting strategies. The use of a skin substitute can also be used when there is uncertainty about the vascularity of the underlying wound bed and whether or not this would support the healing of a skin graft. The medical evidence supports the use of skin substitutes for partial thickness burns. In this patients case, Suprathel was used on both partial and full thickness burns. Therefore, the medical evidence supports the services at issue as it relates to the treatment of partial thickness burns. However, there is a lack of support for the services at issue for the treatment of this patients full thickness burns.