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

Summary Reviewer 


A 22-year-old female enrollee has requested authorization and coverage for Orencia. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees rheumatoid arthritis. The physician reviewer found that the current guidelines recommend tumor necrosis factor (TNF) inhibitors as first-line therapy for patients with active rheumatoid arthritis. The U.S. Food and Drug Administration (FDA) has approved Orencia for the treatment of patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more disease modifying anti-rheumatic drugs (DMARDs) or TNF inhibitors (Maxwell and Singh). Orencia appears to be most effective in patients with active rheumatoid arthritis resistant to either methotrexate or the combination of methotrexate and anti-TNF agents and methotrexate naive patients with early rheumatoid arthritis and poor prognostic indicators (Kremer, et al). These indicators include patients who are methotrexate naive and seropositive for rheumatoid factor (RF), anti-cyclic citrullinated protein (CCP) type 2 or both and had radiographic evidence of joint erosions (Westhovens, et al). This is a case of a patient with presumed active seronegative rheumatoid arthritis who is intolerant to methotrexate. However, the medical records fail to demonstrate what dose and what reaction she had to the methotrexate. Moreover, the documentation does not include evidence of failure or intolerance or contraindications to TNF inhibitors. All told, Orencia is not supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested medication 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 

The patient is a 28-year-old transgender female who is seeking facial feminization surgery.  The Health Insurer has denied coverage for facial feminization surgery. Per the Health Insurer, the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the purpose of medically necessary facial feminization surgery is to relieve gender dysphoria. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life. World Professional Association for Transgender Health, Inc. (WPATH) states, Non-genital surgical proceduresnotably facial feminization surgeryare often of greater practical significance in the patients daily life than reconstruction of the genitals. WPATH notes, These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. The current medical evidence supports the requested services in this patients case. Therefore, the requested facial feminization surgery is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 63-year-old male enrollee has requested reimbursement for Decision Dx Assay testing performed on 7/18/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees melanoma. The physician reviewer found there is insufficient support in the peer-reviewed literature for the testing at issue in this clinical setting. According to the results of analysis of the patients melanoma performed with Decision Dx Melanoma, the tumor was classified as Class 1A with a low risk of near-term within five years metastatic disease, such as 96% metastasis free rate. According to the standard analysis of such risk, the lesions of 1-2 mm depth have a risk of 80-96%. Although the Decision Dx Melanoma signature may be an independent predictor of metastasis risk, there are a lack of peer-reviewed published studies confirming this hypothesis. All told, the Decision Dx Assay testing performed on 7/18/16 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 2

A 63-year-old male enrollee has requested reimbursement for Decision Dx Assay testing performed on 7/18/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees melanoma. The physician reviewer found the Decision Dx Assay tests the tissue genetics of the melanoma and can stratify whether a thin melanoma is high risk for metastasis or not. The patients provider recommended Decision Dx where the genes are examined for certain markers and then the lesion can be further stratified to tell if it is high risk for metastasis. This test has shown some accuracy in thin melanomas like this patients. However, the treatment of this patient would not change based on the results of the testing. Moreover, the testing at issue is not the standard of care. There is a lack of peer-reviewed literature to support its use in the care of patients with thin melanomas to effect health outcomes. Given the lack of support in the peer-reviewed literature, the Decision Dx Assay testing performed on 7/18/16 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 3

A 63-year-old male enrollee has requested reimbursement for Decision Dx Assay testing performed on 7/18/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees melanoma.The physician reviewer found the Decision Dx Assay testing performed on 7/18/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the Decision Dx Melanoma testing should not be used outside of a clinical trial setting. In this case, the patient presented with melanoma of 0.83 mm Breslow depth located on his back. The use of Decision Dx Assay testing is not the standard of care in the treatment of the patients melanoma. As such, the testing at issue is not expected to impact the treatment or outcome of the patients melanoma. Therefore, the testing at issue 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 36-year-old male enrollee has requested authorization and coverage for Botox injections.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the patient has been documented to have migraine, and is stated to have chronic migraine.  Chronic migraine is most easily described as patients with migraines, with headache more days than not (greater than 15 days per month).  Botox has been confirmed to be beneficial for chronic migraine, but studies of episodic migraine have not documented benefit.  In this case, the patients headache frequency is not documented.  Thus, chronic migraine cannot be confirmed, and the requested Botox injections are not medically indicated for the treatment of this patient.  Therefore, 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 Upheld

Summary Reviewer 


A 43-year-old male enrollee has requested reimbursement for a continuous positive airway pressure (CPAP) device provided on 2/9/15. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the clinical indication for CPAP device includes the requirement of documentation that the patient is compliant and is utilizing the CPAP device for at least four hours a night for at least 70% of the nights for a 30 day period. The patient noted he was not using CPAP because of seasonal allergies. There is a lack of documentation demonstrating that the patient utilized the device at issue for a 30 day period. Given the lack of documentation demonstrating compliance, CPAP was not medically necessary for treatment of the patients medical condition. Given the above reasons, the device at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1
A 38-year-old female enrollee has requested authorization and coverage for Humira 40 mg weekly.  The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational for treatment of the enrollees ulcerative colitis. The physician reviewer found that anti-tumor necrosis factor agents, such as Humira and Remicade, have demonstrated efficacy for induction and maintenance of remission in patients with moderate to severe inflammatory bowel disease, but the response is not universal. More than one-third of patients do not respond to induction therapy (primary nonresponse) and even among initial responders, the response wanes over time, sometimes resulting in disease exacerbation. Relative to this patients desire to conceive, after week 20 of pregnancy, chimeric antibodies cross the placenta. However, the consequence of having anti-tumor necrosis factor in a neonate has not been studied until recently. Recent population-based data find that there is no increased risk for birth defects. According to the most recent practice guideline, pregnant women receiving maintenance therapy should continue therapy, and the decision to stop after week 20 is individualized. Because this patient is in remission, there is no need to stop now, nor is there significant concern for an increased risk of an adverse pregnancy outcome. Pregnancy desire is not a contraindication to anti-tumor necrosis factor treatment. If a mother is not treated through her pregnancy, she runs the risk of disease activity, which will be detrimental to her health and her pregnancy. Evidence supports the safety and efficacy of anti-tumor necrosis therapy before and during pregnancy and should not delay the decision to start or optimize therapy. In this patients case, Humira 40 mg weekly is likely to be of greater benefit than other available treatment options. Based upon the information set forth above, the requested medication dosage 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 38-year-old female enrollee has requested authorization and coverage for Humira 40 mg weekly.  The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational for treatment of the enrollees ulcerative colitis. The physician reviewer found that there is data from prospective registry trials indicating that up to one-third of patients on Humira may require an increase in dose to weekly. Rather than abandon the entire class of anti-tumor necrosis factor drugs, modern algorithms suggest increasing Humira to weekly before switching to another class. Thus, there is support for weekly Humira in this patients case. In sum, Humira 40 mg weekly is likely to be superior over other available treatment options. Based upon the information set forth above, the requested medication dosage 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 38-year-old female enrollee has requested authorization and coverage for Humira 40 mg weekly.  The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational for treatment of the enrollees ulcerative colitis. The physician reviewer found that there is sufficient support for the requested medication dosage in this clinical setting. This patient has had uncontrolled disease on dosing every 14 days. In the ULTRA 2 trial by Sandborn and colleagues, it was part of the protocol to change patients to weekly Humira if response was not adequate on Humira every two weeks. The trial advanced non-responders at week 8 to weekly therapy as well as week-8 responders. Both groups contained a fraction that responded to dosing frequency increase. Current guidelines recommend that when anti-tumor necrosis factor level is low, and anti-drug antibody is low or absent (as in this case), the drug dose should be increased. Staying on the dose of 40 mg every other week or changing to a different medication may result in disease flare, disease complications, and hospitalization. For these reasons, the request for Humira 40 mg weekly is likely to be of greater benefit than other available treatment options. Based upon the information set forth above, the requested medication dosage 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 64-year-old female enrollee has requested reimbursement and prospective authorization and coverage for proton beam radiation. The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees medical condition. The physician reviewer found Proton beam radiation was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The use of proton therapy is an accepted radiation technology that has proven efficacy and tolerability. For multiple myeloma, low doses are used to achieve palliation. IMRT and/or proton therapy can allow for better dose conformality of complex shaped targets. However, there is a lack of support for the use of proton therapy over IMRT when delivering such low doses. In this case, the actual radiation planning records are not provided, but the dose exposure of the right eye with IMRT is a mean of 23 Gy and the maximum dose recorded for all other structures are less than 12 Gy with IMRT.  Based on the documentation submitted for review both IMRT and proton beam appear to result in excellent coverage of the tumor with similar toxicity risks. Proton therapy will almost always reduce dose to surrounding normal tissues. Simply demonstrating that proton therapy reduces the dose to some normal tissues does not necessarily demonstrate that it is superior to IMRT.  Thus, proton therapy is not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were not and 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 64-year-old female enrollee has requested reimbursement and prospective authorization and coverage for proton beam radiation. The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees medical condition. The physician reviewer found based on the submitted documentation, proton beam radiation is not likely to be more beneficial in this clinical scenario when compared with conventional treatment such as photon-based intensity modulated radiation therapy (IMRT). The theoretical advantage of proton therapy is that it has a Bragg beak, resulting in less dose to surrounding normal tissue and a lower integral dose (Shin, et al). The main use of proton therapy in the orbital region is in treating uveal melanomas too large for brachytherapy, where it has an accepted benefit over photons (Weber, et al). In the setting of a myelomatous orbital lesion, however, data is lacking due to the rarity of such a clinical scenario. As appropriate, the treating provider has submitted comparison plan data between protons and photon IMRT. While the doses to normal tissue are lower with protons versus IMRT, the IMRT doses are still well below accepted thresholds of toxicity. In other words, the protons are superior dosimetrically as would be expected, but there is unlikely to be any actually clinical benefit, as IMRT is already not expected to lead to any significant side effect. Based on the above, there is not expected to be any clinical benefit of using proton therapy over photon-based IMRT. As such, proton beam radiation was not and is not 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 not and 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 64-year-old female enrollee has requested reimbursement and prospective authorization and coverage for proton beam radiation. The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees medical condition. The physician reviewer found based on the documentation submitted for review, there is a lack of sufficient rationale for the use of proton therapy in the palliative setting for the treatment of an orbital lesion. Currently, there is a lack of clinical data in the medical literature to suggest that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the palliative setting for multiple myeloma. In addition, there is a lack of literature that compares clinical outcomes of proton beam radiotherapy compared to standard photon techniques for orbital metastases. The standard approach in this clinical setting is standard photon techniques. Also, the American Society of Radiation Oncology (ASTRO) emerging technology committee report on proton therapy does not mention the use of proton therapy for this condition (Allen, et al). A comparison of proton technique versus three-dimensional (3D) conformal technique has been submitted and reviewed against published and generally-accepted normal tissue constraints. The comparison shows no clinically relevant reduction in radiation doses with the proton plan compared to the standard intensity modulated plan. The doses that have been provided to show the difference between photon and proton plans are both within acceptable ranges. Although the 3D dose to certain critical structures may be higher, it is still considered an acceptable plan by Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) dose criteria and the difference between the two plans is not considered clinically significant (Marks, et al). Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in this setting. Based on these reasons, proton beam therapy was not and is not likely to be more beneficial than standard treatment with photon techniques. Based upon the information set forth above, the services at issue were not and 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a 14-year-old female enrollee has requested reimbursement and prospective authorization and coverage for residential treatment from 5/21/14 forward.  The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health conditions.] The physician reviewer found the submitted documentation supports the medical necessity of a portion of the services at issue.  Considering that the patient had failed treatment in a less restrictive setting and was engaging in increasingly concerning activity, placement at the residential level of care was initially indicated as the services were reasonably expected to improve her condition at the time, and prevent a more serious episode of illness.  However, the record does not justify the medical necessity of ongoing treatment at the residential level of care from 11/01/14 forward.  The diagnosis of mood disorder, not otherwise specified has not been refined or updated.  There has been no change to the medication regimen which infers an element of clinical stability.  During the family session on 10/27/14, the unit addressed reality and expectation in a healthy manner.  Prior to that appointment, the patient successfully completed a three-day adventure therapy trip.  On 10/31/14, during the individual therapy session, the patient was able to show empathy and acceptance for an unexpected interruption.  Considering the positive clinical trend in the medical records coupled with community practice standards and current practice guidelines, residential treatment services from 5/21/14 through 10/31/14 were medically necessary for treatment of the patients medical condition.  However, services from 11/1/14 onward were not and are not medically necessary based on the documentation provided.  Therefore, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.