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

Summary Reviewer 1

A 62-year-old female has requested authorization and coverage for spine nerve treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees back pain. The physician reviewer found the current medical evidence does not support the requested services in this clinical setting.  Per the records, this patient has received only a single set of diagnostic lumbar medial branch blocks. Manchikanti and colleagues noted the evidence for diagnostic lumbar facet joint nerve blocks and diagnostic sacroiliac intraarticular injections is good with 75% to 100% pain relief as criterion standard with controlled local anesthetic or placebo blocks. Additionally, the literature supports the use of a second set of diagnostic medial branch blocks. In this patients case, the pain relief did not exceed 75%, and a second set of diagnostic medial branch blocks was not performed. Therefore, the requested spine nerve treatment is not likely to be more efficacious than other 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 62-year-old female has requested authorization and coverage for spine nerve treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees back pain. The physician reviewer found in the documentation available for review, the provider does not document a pain diary for the medial branch block done prior to the radiofrequency ablation. The literature is clear regarding how a diagnostic medial branch block should be done prior to radiofrequency ablation; specifically, using a pain diary for the day to verify when the local anesthetic wore off.  Moreover, it is possible the patient would experience the same relief from a steroid injection alone without also having the increased risk from the radiofrequency ablation. No mention of prior failure from facet injections or epidural injections is noted. Therefore, the requested spine nerve treatment is not likely to be more beneficial for treatment of the patients medical condition 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 62-year-old female has requested authorization and coverage for spine nerve treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees back pain. The physician reviewer found there is a lack of support for the requested services in this clinical setting. Sufficient clinical details supporting the requested spine nerve treatment are lacking. The clinical notes are vague and specify only radicular pain. The records do not clearly establish that the patient has back pain of facet origin or referred pain from the facets. Thus, the superior efficacy of the requested spine nerve treatment has not been demonstrated in this patients case.  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 1

A 28-year-old male enrollee has requested reimbursement for ColonSentry testing (CPT code 81479) performed on 10/23/14.  The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found the review of the submitted documentation and relevant literature fails to support the services at issue in this clinical setting. Serum biomarkers for colon cancer screening are not recommended by the National Comprehensive Cancer Network (NCCN) guidelines for colorectal cancer (CRC) screening (Provenzale, et al). According to Fletcher The New York State Department of Health also approved a seven-gene test (ColonSentry) in February 2012 to be used to identify patients at increased risk of colorectal cancer in order to target such patients for monitoring to assure compliance with regular colonoscopy. However, it has not been shown that the test can detect early-stage cancers, for which screening would be most effective, and test sensitivity (61 to 82 percent) and specificity (64 to 77 percent) were only fair for CRC at any stage when tested in populations that included a substantial proportion of patients with known CRC. Based on the lack of support in the peer-reviewed literature, the ColonSentry testing (CPT code 81479) performed on 10/23/14 was not likely to be more beneficial for evaluation of the patients medical condition than other modalities. 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 28-year-old male enrollee has requested reimbursement for ColonSentry testing (CPT code 81479) performed on 10/23/14.  The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found the ColonSentry test is typically performed to help patients decide on whether or not a colonoscopy may be indicated. The ColonSentry test does not replace colonoscopy as the gold standard for colon cancer screening. In this case, the patient has undergone surveillance colonoscopy and the case file does not show any contraindication to future procedures. As such, the ColonSentry testing (CPT code 81479) performed on 10/23/14 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 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 28-year-old male enrollee has requested reimbursement for ColonSentry testing (CPT code 81479) performed on 10/23/14.  The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found based on the documentation submitted for review, the patient may be in a family with Lynch syndrome. However, there is no specific genetic determination that the patient carries the Lynch genetics. Lynch syndrome (hereditary nonpolyposis colorectal cancer) is an autosomal dominant genetic abnormality that brings with it increased risk of multiple types of cancer, including colon cancer, endometrial cancer, and others. Because of this there are recommended programs of surveillance that have been recommended. In relation to colon cancer, affected patients should have colonoscopy every 1-2 years (Lindor, et al). The ColonSentry blood test measures the expression of seven genes whose expression is associated with colorectal cancer. Its purpose is to indicate to a patient his relative risk of the development of colon cancer. However, there is a lack of significant data as yet, to demonstrate any benefit to this test and it is not U.S. Food and Drug Administration (FDA) approved. In addition, it is not included within national guidelines for colorectal cancer screening (Levin, et al). There is also a lack of data to indicate that it provides meaningful data in the management of those with Lynch syndrome. In this case, the patient underwent colonoscopy surveillance, and there is no benefit to the additional use of ColonSentry testing. As such, the ColonSentry testing (CPT code 81479) performed on 10/23/14 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 1

A 43-year-old female enrollee has requested reimbursement for FoundationOne CDx testing performed on 7/16/19. 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 use of next generation sequencing (NGS) or molecular profiling is recommended by the National Comprehensive Cancer Network (NCCN) guidelines for patients with endometrial cancer as well as ovarian cancer. Molecular analysis can help classify difficult cases and provide future therapeutic targets. Individualized molecular tumor profiling holds the promise of enabling personalized selection of molecularly targeted treatment based on the specific genotype identified. The NCCN guidelines recommend tumor molecular testing prior to initiation of therapy for recurrent or persistent ovarian cancer, if not previously done. Testing should include at least BRCA1/2, homologous recombination pathway genes, and microsatellite instability or DNA mismatch repair. This patient has two synchronous cancers, and the use of next generation sequencing may help solidify a treatment plan for this patient. Therefore, FoundationOne CDx testing performed on 7/16/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 43-year-old female enrollee has requested reimbursement for FoundationOne CDx testing performed on 7/16/19. 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 Foundation One assay is a molecular assay of gene mutations found in a variety of cancer cells. The hope is that the assay will identify a specific mutation or target that could guide the clinician as to which chemotherapeutic drug would be useful. Thus far, there is a lack of convincing evidence that the assay adds to the decision making ability or yields a result that is clinically beneficial. Le Tourneau and colleagues did not demonstrate better efficacy when choosing therapy based on such an assay versus the oncologists clinical judgment. In this patients case, the initial treatment was based on the oncologist common practice without the need for Foundation One assay results. In sum, FoundationOne CDx testing performed on 7/16/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 43-year-old female enrollee has requested reimbursement for FoundationOne CDx testing performed on 7/16/19. 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 was diagnosed with endometrial cancer. The patient had a hysterectomy and bilateral salpingo-oophorectomy, and the final pathology showed an endometrioid adenocarcinoma. A portion of the tumor tissue was submitted for the FoundationOne CDx test. The test performed microsatellite assessment, tumor mutational burden, as well as an analysis of mutations in over 400 known tumor suppressor and oncogenes. Endometrial cancers have been analyzed in depth, and the current pathology work-up recommends detailed molecular analysis. These recommendations are present in the National Comprehensive Cancer Network guidelines. Based on the current standard of care, the testing as ordered was medically appropriate. Thus, FoundationOne CDx testing performed on 7/16/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 48-year-old male enrollee has requested reimbursement for Prometheus Anser IFX test performed on 8/24/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of ankylosing spondylitis and sacroilitis plus peripheral inflammatory arthritis. The physician reviewer found the medical literature does not support the superior efficacy of the services at issue in this clinical setting. The Prometheus Anser IFX is not currently routine testing that is performed when a patient has had flares of inflammatory arthritis while on Remicade. Current peer reviewed medical literature and evidence-based studies do not support the routine use of this test for management of inflammatory arthritis patients. On the basis of this lack of peer reviewed evidence, the Prometheus Anser IFX Test performed on 8/24/15 was not likely to be more effective than the available standard therapy for the evaluation of 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 Overturned

Summary Reviewer 2


A 48-year-old male enrollee has requested reimbursement for Prometheus Anser IFX test performed on 8/24/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of ankylosing spondylitis and sacroilitis plus peripheral inflammatory arthritis. The physician reviewer found the medical research shows that anti-tumor necrosis factor agents have been associated to an increasing amount of auto-antibodies resulting in increased risk of infusion reactions, a reduced response to medications and the need for increasing dose adjustments. Up to about 50% of patients treated with infliximab develop these antibodies (Bendtzen, et al. (2006)). In a study by Baert and colleagues, they found that those patients with high antibodies had a higher risk of infusion reactions. In this patients case, he was having a recent flare of ankylosing spondylitis. It was unclear from the examination and supporting laboratory results if he was having a reaction to infliximab due to autoantibodies, which makes the infliximab ineffective and possibly harmful, or if he was no longer responding at his current dose, which would require an increase in medication.  The provider requested serologic testing to assess for antibodies against infliximab. The results of the test were negative and so, the patient was given an increased dose of infliximab and methotrexate. Therefore, for this patient, the testing proved helpful in identifying treatment options. As such, the Prometheus Anser IFX test was better than the standard method of evaluation which would have been to trial an increased dose of the medication and then monitor the patient for a reaction.  All told, the Prometheus Anser IFX test performed on 8/24/15 was superior to the available standard modality for the evaluation of this patients response to his current therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for the 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 48-year-old male enrollee has requested reimbursement for Prometheus Anser IFX test performed on 8/24/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of ankylosing spondylitis and sacroilitis plus peripheral inflammatory arthritis. The physician reviewer found the patient had been stable on Remicade for a long period of time but has experienced recent flaring. This test has been used to identify whether or not antibodies to Remicade are present in those patients currently on the medication. The results from this test assist providers in identifying appropriate therapy for the treatment of their patients. In this patients case, the provider needed to determine if antibodies to Remicade were present. The provider wanted to determine if the patients recent flares were due to a loss of response to Remicade, secondary to antibodies. If this was the case, the medication would have needed to be changed immediately. In this patients case, the test was an effective tool in assisting the patients provider with the management and treatment of this patient. In sum, the Prometheus Anser IFX test rendered on 8/24/15, was more likely to be effective than other standard methods in the evaluation of this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for the 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 27-year-old transgender female who is seeking facial feminization surgery. The Health Insurer has denied authorization and coverage for transfeminine facial contouring. Per the Health Insurer, the requested services are not medically necessary for the treatment of the patient. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. The purpose of medically necessary facial feminization surgery is to relieve gender dysphoria. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, aimproved mental health-related quality of life.a World Professional Association for Transgender Health (WPATH) stated, aNon-genital surgical proceduresanotably facial feminization surgeryaare often of greater practical significance in the patientas daily life than reconstruction of the genitals.a The authors noted, aThese reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition.a Therefore, the requested transfeminine facial contouring is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 44-year-old female enrollee has requested reimbursement for Prometheus testing performed on 4/30/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there are a number of reasons why patients can develop worsening symptoms while on maintenance therapy with a tumor necrosis factor inhibitor.  The patients inflammatory pathway may have escaped the influence of tumor necrosis factor.  The patient may have the presence of antibodies resulting in below therapeutic levels of the anti-tumor necrosis factor agent.  The possibility of Clostridium difficile and other enteric infections also needs to be considered.  However, measuring drug levels and their antibodies is problematic.  The target drug level for any patient is unknown, and it is likely that the tissue level of drug rather than serum level is most important. Additionally, antibody detection is imprecise. Antibodies are often transient and may not be biologically meaningful in vivo.  In sum, the services at issue were 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 44-year-old female enrollee has requested reimbursement for Prometheus testing performed on 4/30/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the current medical evidence has not demonstrated the superior effectiveness of the services at issue.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of adalimumab or the presence of adalimumab antibodies may have an adverse effect on the clinical outcome of a patients response to treatment.  However, while there have been testimonials, there are few well-controlled clinical trials to confirm that the testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  It has not yet 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.  In sum, the services at issue were not likely to have been of greater benefit than other methods of evaluating this patient.  In sum, the services at issue were 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.