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

Summary Reviewer 3


A 57-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 12/17/15 and 1/12/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk for breast cancer.  The physician reviewer found that there is a lack of peer-reviewed literature that supports the use of three dimensional breast tomosynthesis compared to currently available techniques, especially in a patient without an increased risk of breast cancer. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in the peer-reviewed medical literature. For these reasons, the breast tomosynthesis provided on 12/17/15 and 1/12/16 were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 46-year-old female enrollee has requested reimbursement for substance abuse residential treatment provided from 6/16/18 through 6/24/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that in this case, the patients abuse of alcohol and alprazolam was impairing her daily routine and contributing to significant impairment across multiple domains of functionality. Her addictive illness, and co-occurring depression, warranted specialty care. However, by mid-June 2018, there was no evidence of a withdrawal syndrome, psychosocial scenario, psychiatric condition or medical illness that would typically require treatment at the residential level of care. The patient was motivated for recovery. Although she was unsure of the viability of the marriage, she had a safe environment conducive to recovery and supportive family. The physician note from 6/7/18 was unremarkable. The patient was mildly anxious, but stable affectively. Her laboratory studies were normal. There was no mention of distress or problems with her medications, which by then included an anti-craving medication, naltrexone. Further, the patient was not actively engaged in psychiatric care prior to admission, and she had no history of substance use specific chemical dependency treatment, such as outpatient counseling, medication assisted therapy, intensive outpatient services, partial hospitalization or placement in a sober living environment. Modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. There was no evidence to suggest that similarly comprehensive, evidence-based services provided in a less restrictive treatment setting for this stable, motivated and otherwise healthy patient would have been insufficient or inadequate at the time. All told, substance abuse residential treatment provided from 6/16/18 through 6/24/18 were not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 32-year-old male enrollee has requested reimbursement for laboratory testing performed on 12/05/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient was appropriately treated for infectious risks associated with monkey bites. The standard references for management of travel-associated illness do not discuss risk of transmission of hepatitis from monkey bites. The medical literature does not indicate that monkey bites are a source of transmission for hepatitis viruses. The testing ordered after his return to the United States was not medically indicated. Therefore, laboratory testing performed on 12/05/18 was not medically necessary for the evaluation for the patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 27-year-old female enrollee has requested reimbursement for genetic testing including methylenetetrahydrofolate reductase (MTHFR) gene analysis, common variants, and factor V Leiden mutation testing provided on 7/1/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for bleeding disorder.  
 
 The physician reviewer found that there is a lack of large well defined studies that support the superiority of the services at issue when compared to the available standard options of evaluating this patient.  A January 2011 guideline from the Evaluation of Genomic Applications in Practice and Prevention (EGAPP) Working Group recommends against routine testing for factor V Leiden and/or the prothrombin 20210 mutation in asymptomatic family members of patients with venous thromboembolism. In this patients case, the genetic testing would not have provided a greater value in the assessment of this patients condition over the standard options available. As such, genetic testing including MTHFR gene analysis, common variants, and factor V Leiden mutation testing provided on 7/1/17 was not likely to have been superior over any of the available standard methods of evaluating this patient.

Based upon the information set forth above, the services at issue were 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 2

A 27-year-old female enrollee has requested reimbursement for genetic testing including methylenetetrahydrofolate reductase (MTHFR) gene analysis, common variants, and factor V Leiden mutation testing provided on 7/1/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for bleeding disorder.  
 
 The physician reviewer found that there is support for a portion of the services at issue in this clinical setting. This patient has a family history of a prothrombin gene mutation. Most clinicians would recommend testing for all five major thrombophilias, which includes factor V Leiden mutation. It is not uncommon for patients to carry more than one mutation. Testing for factor V Leiden mutation is likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Regarding MTHFR mutation, homozygosity for these genetic variants is a relatively common cause of mildly elevated plasma homocysteine levels in the general population, often occurring in association with serum folate levels in the low normal range. High quality epidemiologic studies have not found a significant increase in venous thromboembolism risks among individuals homozygous for MTHFR polymorphisms. As such, testing for MTHFR is unlikely to be more beneficial than any available standard of care. Therefore, a portion of the genetic testing provided on 7/1/17 was likely to be more effective than the standard therapy available. Specifically, common variants and factor V Leiden mutation are more likely to be effective than the available standard therapy.  Based upon the information set forth above, a portion of the services 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 partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3
A 27-year-old female enrollee has requested reimbursement for genetic testing including methylenetetrahydrofolate reductase (MTHFR) gene analysis, common variants, and factor V Leiden mutation testing provided on 7/1/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for bleeding disorder.  
 
 The physician reviewer found that the Pulmonary embolism (PE) and DVT may be caused by hereditary thrombophilias. The increased risk is worth knowing especially in situations of pregnancy, estrogen therapy, and prolonged immobility, such as surgery, long car trips, or long airplane flights. These complications may be prevented by appropriate interventions. There is strong medical evidence supporting factor V Leiden testing. There is a known interaction between estrogens and the mutation. Importantly, research indicates that the prothrombin G20210A mutation adds to this risk such that compound heterozygous patients can have up to 20 fold increased odds of developing DVT (Emmerich, et al).  Accordingly, this patients case genetic testing including MTHFR gene analysis, common variants, and factor V Leiden mutation testing provided on 7/1/17 was likely to have been of greater benefit than the standard methods of evaluating this patients medical condition. 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 1

A 39-year-old male enrollee has requested reimbursement for the Factor V Leiden genetic testing and homocysteine testing provided on 3/23/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees superficial vein thrombophlebitis. The physician reviewer found that most experts recommend testing for the five major inherited hypercoagulable risk factors including protein S, C, and antithrombin deficiencies, factor V Leiden and prothrombin gene mutation as well as for anti-phospholipid syndrome in patients less than age 45. However, testing for homocysteine levels and mutational analysis for the responsible gene, methylene tetrahydrofolate reductase (MTHFR), is not routinely recommended. Although elevated levels of homocysteine can be found in patients with thrombosis, the causal role of hyperhomocysteinemia in thrombosis remains unclear. In addition, lowering homocysteine levels with folic acid, pyridoxine, and vitamin B12 does not appear to reduce the rate of VTE in patients with hyperhomocysteinemia. Thus, Factor V Leiden is supported as beneficial, while homocysteine testing is not likely to be more beneficial. Accordingly, the Factor V Leiden genetic testing provided on 3/23/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the homocysteine testing performed on 3/23/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, a portion of 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 partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 39-year-old male enrollee has requested reimbursement for the Factor V Leiden genetic testing and homocysteine testing provided on 3/23/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees superficial vein thrombophlebitis. The physician reviewer found that there is extensive literature supporting the testing that was done in this case. The Factor V mutation also known as Factor V Leiden has the potential to induce hypercoagulopathy in certain circumstances. Importantly, the Prothrombin G20210A mutation adds to this risk such that compound heterozygous patients can have increased odds of developing deep vein thrombosis (Emmerich, et al). Similarly, patients with hyperhomocysteinemia and Factor V Leiden are at increased risk for deep vein thrombosis (Ridker, et al). The most common genetic cause for hyperhomocysteinemia is the thermolabile variant of the methylenetetrahydrofolate reductase (MTHFR) enzyme. This is due to homozygosity for the TT genotype at codon 677 (Kluijtmans, et al). If this patient was found to be a carrier of multiple mutations predisposing to thrombosis, then a recurrent thrombotic event could be prevented with medical therapy and activity modification. For these reasons, the Factor V Leiden genetic testing and homocysteine testing provided on 3/23/16 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 39-year-old male enrollee has requested reimbursement for the Factor V Leiden genetic testing and homocysteine testing provided on 3/23/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees superficial vein thrombophlebitis. The physician reviewer found that patients who have had a deep venous thrombosis have a high prevalence of inherited thrombophilic disorders (Merriman and Greaves). However, the current medical literature does not support routine Factor V Leiden genetic testing and homocysteine testing for patients based on the presence of superficial venous thrombosis (Nakashima and Rogers). All told, the Factor V Leiden genetic testing and homocysteine testing provided on 3/23/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the 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 39-year-old female enrollee has requested reimbursement for Prometheus Anser ADA testing performed on 1/27/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that based upon the medical records provided, the Prometheus Anser ADA testing performed on 1/27/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Maximizing the efficacy of therapies, for inflammatory bowel disease (IBD), while minimizing their toxicity remains the principal objective in developing management strategies for IBD patients. Recognition of the factors influencing therapeutic response allows clinicians to individualize dosing regimens to meet this objective. In order to optimize IBD therapy, it is critical that prescribers understand that standard dosing is insufficient for most patients, given the interindividual variability relating to response and tolerability. The loss of response to adalimumab can be due to subtherapeutic infliximab/adalimumab levels or the presence of antibodies to infliximab/adalimumab. The available data suggest that measuring drug and/or antibody levels could help clinicians to optimize anti-tumor necrosis factor (TNF) therapy by adjusting drug doses or switching to alternative therapies in patients who are unlikely to respond to continued treatment with a particular agent. Prometheus Anser ADA diagnostic test is considered safe and effective in optimizing therapy in patients with inflammatory bowel disease such as Crohn's disease who are being treated with anti-TNF agents such as Humira and infliximab. In this case, Prometheus Anser ADA assay was likely more beneficial than empiric dose escalation of Humira in this patient with suspected flare-up of her Crohns disease. 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 2

A 39-year-old female enrollee has requested reimbursement for Prometheus Anser ADA testing performed on 1/27/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the testing at issue was not likely to be more effective for this patient than other available options. Prometheus Anser ADA is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions, as well as delayed hypersensitivity reactions. There are few well controlled clinical trials to confirm that use of the Prometheus Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. Generally, except on a rare case-by-case basis, diminished or suboptimal response to infliximab or adalimumab can be managed in several ways such as shortening the interval between doses, increasing the dose, switching to a different anti-tumor necrosis factor (TNF) agent (in patients who continue to have loss of response after receiving the increased dose), or switching to a non-anti-TNF agent based on clinical observation in lieu of Prometheus Anser ADA testing. In this case, the Anser testing was of questionable clinical significance. Moreover, the Prometheus Anser ADA results did not immediately alter the patients treatment course or result in a net positive clinical outcome. 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 39-year-old female enrollee has requested reimbursement for Prometheus Anser ADA testing performed on 1/27/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the Anser ADA testing was ordered to determine the etiology for possible loss of response to Humira and to direct the management of the patients Crohns disease. The test revealed antibodies and that the drug was present. However, the use of Anser ADA has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. The effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with adalimumab may experience loss of response. However, the appropriate method for determination of the cause for loss of response is not clear. The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature (Karmiris, et al; Imaeda, et al; Lichtenstein, et al). These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. The study by Karmiris and colleagues found no direct relationship between trough serum adalimumab concentration or anti-adalimumab antibody and short-term treatment efficacy. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. Clinical guidelines for management of inflammatory bowel disease do not recommend testing for anti-drug antibody during clinical management (Lichtenstein, et al). A review article by Yanai and Hanauer reported that prospective controlled trials are direly needed to investigate the optimal tailored management in individual patients who lose response. In sum, there is a lack of sufficient evidence in the peer-reviewed literature to establish the testing at issue as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was 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 

A 49-year-old transgender female enrollee has requested reimbursement for tracheal shave provided on 3/26/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. This patient has well-documented gender dysphoria. Per her medical records, she had social anxiety and depression related to being perceived as male by others. The records document clinically significant distress from having masculine features. Under these circumstances, the tracheal shave performed was medically necessary for the treatment of her gender dysphoria. World Professional Association for Transgender Health (WPATH) criteria for surgery state that other surgeries for assisting in body feminization include reduction thyroid chondroplasty (reduction of the Adams apple), voice modification surgery, suction-assisted lipoplasty (contour modeling) of the waist, rhinoplasty (nose correction), facial bone reduction, face-lift, and blepharoplasty (rejuvenation of the eyelid). The current medical evidence supports the services at issue in this clinical setting. Therefore, tracheal shave provided on 3/26/18 was 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.