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

Summary Reviewer 2

A 54-year-old male enrollee has requested authorization and coverage for neurostimulator electrode array and pulse generator. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the patient has obstructive sleep apnea and has no nasal obstruction. Drug-induced sleep endoscopy showed no concentric collapse at velum and primarily anterior posterior collapse. The patient has not been able to tolerate the continuous positive airway pressure device. The Inspire device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of obstructive sleep apnea. The patient is a candidate for the Inspire device, given the intolerance to continuous positive airway pressure, anterior posterior collapse, and body mass index and apnea-hypopnea index within FDA criteria. In sum, CPT codes 64568 and 0466T are likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 54-year-old male enrollee has requested authorization and coverage for neurostimulator electrode array and pulse generator. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient meets clinical criteria for consideration of surgical management of his obstructive sleep apnea symptoms. He has undergone prior drug induced sleep endoscopy which documented the location of obstruction with anterior posterior but no concentric collapse at the tongue base.   The patient had trialed continuous positive airway pressure therapy, but was intolerant of the use of these devices. Clinical studies of the use of hypoglossal nerve stimulation suggested that the patients only benefit from this device with a body mass index less than 32, and this patient meets this criteria. Boon and colleagues noted that selective upper airway stimulation is a safe and effective therapy for patients with obstructive sleep apnea and represents a powerful option for its surgical treatment. Woodson and colleagues noted long-term improvements with upper airway stimulation and demonstrated that adverse events were uncommon. There is sufficient support for the requested services in this clinical setting. Thus, CPT codes 64568 and 0466T are likely to be more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 64-year-old male enrollee has requested reimbursement for the DecisionDx melanoma assay testing provided on 9/1/16. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the records indicate the patient presented to his provider with a recently diagnosed 1.4 mm Breslow depth melanoma on the left flank. The National Comprehensive Cancer Network (NCCN) has determined that this type of gene testing for melanoma is not recommended for routine use and should not be used outside of a clinical trial setting. Currently, the DecisionDx melanoma gene test is not considered to be the standard of care. The DecisionDx melanoma gene test is based on studies of ocular melanoma and it has not established that the findings are extended to cutaneous melanoma. For these reasons, the DecisionDx melanoma assay testing provided on 9/1/16 was not medically necessary for evaluation of this patients melanoma. Based on the foregoing discussion, the testing at issue was not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 63-year-old male enrollee has requested reimbursement for intensity modulated radiation therapy provided from 12/01/16 through 1/13/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for treatment of the enrollees rectal cancer. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. Standard treatment for rectal cancer is with three-dimensional conformal techniques. Currently, there is a lack of clinical data in the medical literature to suggest that treatment with intensity modulated radiation therapy offers a clinical benefit compared to conventional radiation therapy techniques for tumors of the rectum.  Consensus group guidelines do not support the use of intensity modulated radiation therapy in this setting.  Also, a phase II study by Hong and colleagues which examined the use of intensity modulated radiation therapy in patients with rectal cancer found no benefit when compared to historical controls. The dose comparison was reviewed as well and shows no clinically significant benefit with the use of intensity modulated radiation therapy over standard three-dimensional techniques. All told, intensity modulated radiation therapy provided from 12/01/16 through 1/13/17 was 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 Overturned

Summary Reviewer 

The patient is a 10-year old male. The patientas parent has requested reimbursement for 92507 (treatment of speech, language) provided from 1/04/20 through 6/27/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The patient has autism spectrum disorder and ADHD, predominantly inattentive subtype He has significant impairment in the appropriate social use of pragmatic language, which is causing difficulty with social interaction with his peers and adults. His language difficulties are also adversely affecting his school performance. The patient will be at significant risk of bullying, anxiety and depression as a result of his language impairment. Recently published guidelines from the American Academy of Pediatrics on the management of children with autism spectrum disorder note, aImprovement in ratings of conversational competence by parents and of classroom learning skills by teachers supports the recommendation for social skills and social language interventions for students with autism spectrum disorder.a The authors noted, aChildren and youth with autism spectrum disorder often have deficits in pragmatic language that can affect social interaction with adults and peers and academic performance as more complex language becomes required for reading comprehension and analysis of information. In addition, literal interpretation of language and difficulty in understanding the intent of other people leads to behavioral challenges in some people with autism spectrum disorder and affects success in school, leisure activities, and employment.a Helland and Helland recommended that the substantial influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism, and that further development of therapy plans and interventions targeting pragmatics is strongly needed. Therefore, 92507 (treatment of speech, language) provided from 1/04/20 through 6/27/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 43-year-old female enrollee has requested authorization and coverage for breast reduction mammoplasty. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees symptomatic macromastia. The physician reviewer found that Breast reduction surgery is medically necessary in this patients case. The patient has well documented symptoms for macromastia and medical treatments have not improved her symptoms. The medical literature indicates that symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for treatment of this condition. Additionally, nonoperative treatments are not likely to improve pain. Instead, the evidence appears to support that surgery may be the most effective treatment for symptomatic relief.  Collins and Kerrigan report that data from the BRAVO (Breast Reduction Assessment Value and Outcomes) study, which prospectively followed 243 patients with symptomatic macromastia, found that nonoperative treatment options did not provide lasting relief from pain. The authors noted  Breast hypertrophy has a significant impact on womens health status and quality of life as measured by validated and widely used self-report instruments including the SF-36, MPQ, MBSRQ, and EuroQol. In women presenting for surgery, nonsurgical measures including weight loss, physical therapy, special brassieres, and medications were not effective in providing permanent relief of breast-related symptoms. In contrast, both pain and overall health status were markedly improved by breast reduction, essentially restoring functional status to that of age-matched norms. A 2014 study by Strong and Hall-Findlay concluded, We found that reduction mammaplasty has a positive impact on a range of symptoms, even with lower volume resections and regardless of body surface area-calculated adjustments. This adds further weight to the argument that patients should not be denied access to the surgery based on arbitrary volume restrictions. We advocate freedom for the surgeon to make a decision on potential benefits of surgery based around the needs of each individual patient. In this patients case, the records document that she has large pendulous breasts with shoulder grooving and the classic symptoms for macromastia. Breast reduction is a treatment that has been proven effective and curative for symptomatic macromastia. Evidence based peer reviewed studies confirm the benefits of breast reduction surgery for individuals with upper torso pain due to breast hypertrophy. As such, nonoperative treatments are unlikely to improve this patients pain. Therefore, the breast reduction mammoplasty is medically necessary for the treatment of this patients medical condition.
Therefore, for the reasons stated above, the requested procedure is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 60-year-old female enrollee has requested authorization and coverage for Harvoni for 12 weeks. The Health Insurer has denied this request indicating that the requested medication quantity is not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found the requested medication quantity is not medically necessary for the treatment of this patient.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  However, in this patients case, the Health Insurer has offered coverage for Harvoni for eight weeks.  Per the medical evidence, since the patients viral load is less than 6,000,000 IU/mL, Harvoni for eight weeks is medically appropriate.  Therefore, the requested medication quantity is 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 25-year-old male enrollee has requested authorization and coverage for Daklinza 60 mg and Sovaldi 400 mg for 12 weeks.  The Health Insurer has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  In treatment-naive genotype 3 patients, the guidelines recommend therapy with Sovaldi and Daklinza for 12 weeks.  All told, the requested Daklinza 60 mg and Sovaldi 400 mg for 12 weeks are medically indicated for the treatment of this patient.  Therefore, the requested medications are 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 1A 56-year-old male enrollee has requested reimbursement for FoundationOne testing performed on 3/14/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees recurrent myxofibrosarcoma.  The physician reviewer found that Currently recognized and accepted molecular evaluation and classification of soft tissue sarcoma (STS) include standard histological evaluation (National Comprehensive Cancer Network guidelines). Broad genomic panel testing such as FoundationOne is not considered standard therapy. In general, to demonstrate clinical utility of panel genetic testing, such as FoundationOne, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. There is currently a lack of such trials that have been published. The available literature on clinical utility consists of a small number of uncontrolled studies, and nonrandomized controlled trials that use imperfect comparators. This evidence is not sufficient to make any conclusions as to its clinical utility in this patients case. In addition, there is potential for harm if ineffective therapy is given based on test results, because there may be adverse effects of therapy in absence of a benefit. As a result, the use of expanded mutation panel testing for targeted treatment in cancer is considered unproven and should only be conducted in the setting of a clinical trial. Accordingly, FoundationOne testing performed on 3/14/17 was not likely have been of greater benefit than the standard options available for the evaluation of this patients medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2
A 56-year-old male enrollee has requested reimbursement for FoundationOne testing performed on 3/14/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees recurrent myxofibrosarcoma.  The physician reviewer found that this documentation provided supports the efficacy of the services at issue in this clinical setting. Myxofibrosarcoma is a rare cancer that is found to have a very heterogeneous genetic make up. Treatment is difficult due to rarity and lack of established guidelines. Genetic profiling, such as with FoundationOne testing, provides genetic profiling to help guide therapeutic decision making. Accordingly, in this patients case, FoundationOne testing performed on 3/14/17 was likely to have been more effective than the standard methods of evaluating this patients medical condition. Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 56-year-old male enrollee has requested reimbursement for FoundationOne testing performed on 3/14/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees recurrent myxofibrosarcoma.  The physician reviewer found that this patients tumor was submitted to FoundationOne for molecular testing to identify mutations that allow enrollment in appropriate clinical trials or the use of an approved therapy that matches the identified mutation. The accessibility of this technology is directly affecting clinical practice because oncologists frequently encounter situations where cancers progress on standard therapies. At that juncture, usually the medical literature is consulted to use something that has been tested in clinical protocols or the patient is enrolled into an active protocol. This process is considered standard of care. Recently, it has become important to identify mutations that may be amenable to targeted therapy. A study of 86 patients was published in the Journal of Clinical Oncology where the progression free survival on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage (Von Hoff, et al). FoundationOne has developed a panel of 400 oncogenes and tumor suppressors to be tested by next generation sequencing in hematologic malignancies and sarcomas. There are many parallels in the molecular genetics between soft tissue sarcomas and hematologic malignancies. For example, dermatofibrous protuberans are characterized by recurrent translocation involving PDGFB, which may be targeted by imatinib.  Invariably, this patient may be offered something off label or a phase I/II clinical trial but the results from molecular profiling offer a rational selection of the next regimen. In sum, FoundationOne testing performed on 3/14/17 was likely to have been more efficacious than the available options for the evaluation of this patients medical condition. Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 30-year-old female enrollee has requested authorization and coverage for cervical total disc replacement surgery and one day inpatient services. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees neck pain.   The physician reviewer found that the U.S. Food and Drug Administration (FDA) has required a seven year post approval study to determine the long-term safety and effectiveness of the Mobi-C device. That study is ongoing and has yet to be reported. Despite the findings by Davis and colleagues at four-year follow-up, cervical artificial disc replacement is not indicated for symptomatic multi-level disease, especially in patients with multilevel degenerative disc disease. This patient has ill defined, vague upper extremity symptoms not representative of a cervical radiculopathy with matching dermatomal and myotomal symptoms and findings (Corey and Comeau). She is noted to have a cervical myelopathy, but there is a lack of substantiating symptoms and findings of increased tone, spasticity, gait disturbance, bowel or bladder problems, hyperreflexia, or pathologic reflexes. Further, there is no correlation on imaging with her clinical examination. She has no symptoms or signs substantiating the C4-5 or the C5-6 level as her pain generator and her pain generator has not been identified. She has annular tears at C3-4, C4-5, C5-6, and C6-7. Disc protrusion of 1 or 2 mm is not clinically significant and her cord shadow is normal. There is no significant compression or deviation of her cord. All told, the use of two level Mobi-C total disc replacement and one day inpatient services for this patient is not likely to be more beneficial than standard 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 30-year-old female enrollee has requested authorization and coverage for cervical total disc replacement surgery and one day inpatient services. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees neck pain.   The physician reviewer found that recent literature suggests that total disc replacement may provide well selected patients with superior health outcomes as compared to anterior cervical discectomy and fusion for one- and two-level degenerative disc disease. Bae and colleagues compared outcomes in a prospective randomized, U.S. Food and Drug Administration (FDA) investigational device exemption clinical trial. The authors reported that at four-year follow-up, each group demonstrated improvement in clinical outcome measures and a comparable safety profile. Davis and colleagues reviewed total disc replacement as surgical treatment of degenerative disc disease at one or two contiguous levels of the cervical spine and found similar outcomes when compared with anterior cervical discectomy with fusion (ACDF). Given this patients clinical findings and complaints, she is likely to obtain greater benefit from the requested cervical total disc replacement surgery and one day inpatient services than treatment with standard alternatives.  Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.