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

Summary Reviewer 2

A 46-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the Inspire device was approved by the US Food and Drug Administration for the treatment of moderate to severe obstructive sleep apnea refractory to continuous positive airway pressure (CPAP). However, a meta-analysis by Kompelli and colleagues found that contemporary
hypoglossal nerve stimulation research consisted of single-arm clinical trials and case series, with a high likelihood of publication bias and a lack of comparative trials of hypoglossal nerve stimulation versus existing alternatives, such as upper airway surgery. They concluded, aHypoglossal nerve stimulation may not be the definitive choice for second line therapya for obstructive sleep apnea. A meta-analysis by He and colleagues evaluated the effectiveness of uvulopalatopharyngoplasty and its modifications for obstructive sleep apnea, demonstrating improved objective and subjective outcomes for at least 34 months after uvulopalatopharyngoplasty. The authors reported that uvulopalatopharyngoplasty and its modification are an effective surgical method for adult patients with obstructive sleep apnea both short-term and long-term after the surgery. Overall, there is insufficient high-quality, peer-reviewed evidence to support the use of hypoglossal nerve stimulation over other available therapies. Therefore, hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System is not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 46-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the medical evidence supports the requested services in this setting. This patient has already failed APAP therapy and is not an optimal candidate for oral appliance therapy due to the severity of his
obstructive sleep apnea. The alternative, no treatment, would lead to potential harms, such as increased medical c-morbidities including hypertension, diabetes, congestive heart failure, myocardial infarction, and stroke. There is sufficient evidence in the peer-reviewed literature to support the safety, efficacy, and long-term outcome in the treatment of obstructive sleep apnea with hypoglossal nerve stimulation or Inspire airway stimulation. Multiple published studies show clinically significant decreases in observed mean apnea-hypopnea index and Epworth Sleepiness Scale score, combined with improvements in quality-of-life scales. There is ample evidence supporting the safety, efficacy, and long-term outcome in the treatment of obstructive sleep apnea with the Inspire device. Therefore, hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 62-year-old male enrollee has requested reimbursement for services (Foundation One testing) performed on 2/07/19. 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 there is sufficient support for the services at issue in this clinical setting. The prognosis of patients with recurrent or metastatic head and neck squamous cell cancer is generally poor. Treatment options include single-agent therapy and combination regimens using either conventional cytotoxic chemotherapy and/or molecularly targeted agents combined with best supportive care. Conventional cytotoxic drugs, checkpoint inhibitor immunotherapy, and molecularly targeted compounds have activity in metastatic and recurrent head and neck cancer. The National Comprehensive Cancer Network indicates that the best management of any patient with cancer is in a clinical trial. Molecular profiling can help identify available therapies (such as immunotherapy) or potential for clinical trials. Therefore, services (Foundation One testing) performed on 2/07/19 were likely to have been more beneficial than other standard methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 62-year-old male enrollee has requested reimbursement for services (Foundation One testing) performed on 2/07/19. 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 is a molecular assay that explores the mutations of an individuals 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. However, at this time, there is a lack of convincing evidence that the assay adds to the decision making ability or yields as result that is clinically useful in a significant number of patients. A randomized study by Le Tourneau and colleagues did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the oncologists clinical judgment. In sum, services (Foundation One testing) performed on 2/07/19 were not likely to have been more beneficial than other standard methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 62-year-old male enrollee has requested reimbursement for services (Foundation One testing) performed on 2/07/19. 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 has recurrent metastatic disease. He has been well managed so far and was empirically tried on standard regimens. Since his tumor has progressed, referral for clinical trials is appropriate. This could be facilitated by mutational testing of the tumor. Some testing that may provide insight are KRAS, TP53, and BRAF, which are included in these panels. BRAF mutations may suggest alternative targeted therapies that may be better than those selected empirically. Von Hoff and colleagues performed a study of 86 patients. The progression-free survival on regimen selected by molecular profiling was compared to the progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has significant results for patients with stage IV tumors. In this patients case, the results from molecular profiling may offer a rational selection of the next regimen. Thus, services (Foundation One testing) performed on 2/07/19 were likely to have been more beneficial than other standard methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The patient is a 43-year-old female who has a history of right sided low back. She reported increasing low back pain over the past several years. The patient has requested authorization and coverage for sacroiliac joint fusion.  The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patients low back pain. There is a lack of long term studies that demonstrate the superior efficacy of the requested procedure in this clinical setting. The effectiveness of sacroiliac joint fusion when compared to standard treatment protocols remains unconvincing as a treatment modality for patients who are diagnosed with low back pain. In this patients case, the documentation does not support evidence of sacroiliac joint instability, fracture, or lesion. A magnetic resonance imaging was noted as showing degenerative disc disease but no lesions were found. The diagnostic imaging does not confirm a medical condition that would provide an indication for sacroiliac joint fusion. Thus, the medical evidence does not support the efficacy of the requested procedure in this patients case. As such, sacroiliac joint fusion is not likely to be of greater benefit for treating this patients medical condition than the available standard treatment methods. Therefore, based upon the information set forth above, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

The patient is a 43-year-old female with right sided low back and sacroiliac pain that has failed conservative treatment. The provider has recommended a minimally invasive sacroiliac fusion using the I-Fuse implant. A review of her medical record indicates a history of chronic right sided low back and buttock pain that does not radiate down the leg. She received excellent relief from the first right sacroiliac joint injection. The magnetic resonance imaging (MRI) scan does show degenerative disc disease at L5-S1 but there is no neuro-compressive lesion. There is no clinical evidence of radiculopathy. The provider has documented failed conservative treatment including physical therapy and medications. The patient has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request on the basis that the requested services are investigational for the treatment of this patient. The medical evidence show that sacroiliac joint degeneration is a common cause of chronic low back pain, which is under diagnosed.  Minimally invasive fusion procedures have demonstrated successful pain relief.  Among these implants, the triangular titanium implants such as I-fuse have been used. Recent medical literature has documented two year follow up of these procedures demonstrating meaningful clinical improvement and maintained pain relief as well as evidence of a solid fusion on imaging studies. Cross and colleagues performed a study of patients with sacroiliac joint dysfunction who were treated with minimally invasive sacroiliac joint fusion using triangular titanium implants. The results from their study showed marked improvements in pain, disability and quality of life at two years. Imaging showed that bone apposition to implants was common but radiographic evidence of intraarticular fusion within the joint may take more than one year in many patients. This case illustrates the difficulty encountered in making an accurate diagnosis of chronic low back pain that does not respond to conservative measures.  In the absence of evidence of neural compression on the MRI scan and in the presence of clinical findings of sacroiliac pain, which is relieved by injecting the sacroiliac joint, the requested procedure using the minimally invasive technique is likely to be successful in this individual.  Accordingly, the request for a sacroiliac joint fusion is likely to be more effective in treating this patients low back pain than the available standard techniques. Therefore, based upon the information set forth above, the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 42-year-old female enrollee has requested reimbursement for substance abuse partial hospitalization services provided from 8/16/14 through 9/01/14.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  This patients opioid use disorder and concomitant abuse of benzodiazepines further exacerbated the risk for an unfavorable outcome.  Her addiction dominated her daily routine and generated distress.  Additionally, her opioid use strained meaningful relationships and caused significant impairment across multiple domains of functionality.  In this patients case, the treatment provided was safe, appropriate and consistent with good practice.  The services were reasonably expected to improve her condition and prevent a more serious episode of illness.  Further, the duration of the disputed treatment was within community practice standards.  All told, substance abuse partial hospitalization services provided from 8/16/14 through 9/01/14 were medically necessary for the treatment of this patient.  Therefore, the services at issue were 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 60-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees prostate cancer. The physician reviewer found that upon review of available data, the requested proton therapy is not medically necessary for treatment of this patients prostate adenocarcinoma. The Health Insurer states that the patient can be treated with photon based intensity modulated radiation therapy (IMRT). In the peer-reviewed medical literature, Trofimov and colleagues reported that dosimetric studies have shown a benefit in bladder and rectal exposure with proton therapy. However, this benefit has not been demonstrated to result in fewer clinical side effects or improved health outcomes (Sheets, et al; Coen, et al; Yu, et al; Hoppe, et al). In addition, the largest available retrospective study showed that gastrointestinal toxicity was actually higher with proton therapy when compared to photon therapy (Sheets, et al). Moreover, cancer control rates are reportedly similar with photon and proton beam radiation therapy (Coen, et al). All told, there is a paucity of scientific data demonstrating that proton beam radiation therapy is medically necessary for treatment of this patients prostate cancer. Based on the foregoing discussion, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 59-year-old female enrollee has requested reimbursement for A0431 ambulance service - conventional air services - transport one way provided on 12/1/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees sore throat and fever. The physician reviewer found that air ambulance services are supported as medically necessary when a patient meets specific criteria. These circumstances include when the point of pickup is inaccessible by land or there is a great distance or obstacle involved in land transport. Another circumstance is when the time needed to transport the patient by land poses a threat to a patients survival or the proper equipment needed for the patient is not available on a land ambulance. A patient might also require air ambulance services in order to be transferred from one facility to another in order to receive specialized services. In such a case, the patient must be transferred to the closest facility capable of providing the specialty services. In this case, the patient presented with pneumonia status post lung transplant requiring anti-rejection immunosuppressive medications. The patient was at elevated risk for developing a rejection of her transplanted lungs and it was critical that she be treated in a facility capable of managing such complications. CMC did not have the specialty services to provide inpatient care for this patient and the documentation suggests that CUH was the closest facility capable of providing the appropriate level of care. The time necessary to transport the patient by ground ambulance would have been at least six hours, which would have posed a danger to this patient, who was tachypneic, had a central venous access and required supplemental oxygen. Given these findings, the A0431 ambulance service - conventional air services - transport one way provided on 12/1/17 were medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 36-year-old female enrollee has requested reimbursement for Botox injections received on 10/14/14.  The Health Insurer has denied this request indicating that the services at issue were investigational for treatment of the enrollees medical condition. The physician reviewer found review of the submitted documentation and relevant literature supports the use of Botox injections in this clinical setting. The documentation submitted for review documents the patient has chronic migraine. In addition, the patient has failed at least two classes of preventive agents. Botox is standard therapy for treatment of chronic migraine, and has been shown to be as effective or more effective, than medications available to treat chronic migraine. In addition, Botox is U.S. Food and Drug Administration (FDA) approved for the treatment of chronic migraine. For the reasons provided, the Botox injections at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy Based upon the information set forth above, the services at issue were 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 36-year-old female enrollee has requested reimbursement for Botox injections received on 10/14/14.  The Health Insurer has denied this request indicating that the services at issue were investigational for treatment of the enrollees medical condition. The physician reviewer found based on the documentation provided for review, Botox injections are supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. This patient has a diagnosis of chronic migraine, with reported baseline of more than 15 headache days per month of severe headaches. She has been on multiple preventives, and multiple abortives. The records indicate a robust improvement with Botox at appropriate doses. In addition, Botox therapy is proven for chronic migraine, and in this patient, has been successful, while prior standard therapies have been unsuccessful. Based upon the information set forth above, the services at issue were 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 3


A 36-year-old female enrollee has requested reimbursement for Botox injections received on 10/14/14.  The Health Insurer has denied this request indicating that the services at issue were investigational for treatment of the enrollees medical condition. The physician reviewer found Botox injections were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Although Botox is not a first-line therapy for all patients with migraines, there is adequate literature supporting its use for this indication in some patients. The therapy is U.S. Food and Drug Administration (FDA) approved for migraine. In this particular case, the patient failed numerous standard therapies for migraine, including two prophylactic classes of therapies, an anti-seizure medication and an antidepressant medication.  The patient also responded to a course of Botox with a reduction of headaches per month. For this reason, the services at issue were likely to be more beneficial for treatment of the patients chronic migraine than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

An 18-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that transcranial magnetic stimulation has been approved by the U.S. Food and Drug Administration (FDA) for use in individuals with major depressive disorder who have not had a satisfactory response to at least one antidepressant trial in the current episode of illness. Furthermore, the FDA has approved transcranial magnetic stimulation for adults with no distinction being made that the adult must be 21 and older, not 18 and older. In this case, the patient has met the criteria for transcranial magnetic stimulation established in current psychiatry guidelines. Therefore, transcranial magnetic stimulation is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 51-year-old male has requested reimbursement for gene expression profiling performed on 5/14/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. 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 may add a bit more 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 risk of metastasis. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients undergoing sentinel node biopsy. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year data of Balch. Most importantly, it is unclear whether DecisionDx-Melanoma data can be used to make clinical decisions. Therefore, gene expression profiling performed on 5/14/17 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.