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

Summary Reviewer 3


A 62-year-old female enrollee has requested reimbursement for ChemoFX assay performed on 5/08/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found in vitro drug testing on patients tumor cells prior to applying chemotherapy is an appealing idea, but it is difficult to put into clinical use.  The most thorough evaluation of these technologies was performed by the American Society of Clinical Oncology in 2004.  In their review of this technology, the panel concluded that such in vitro drug testing should be limited to clinical trials.  There is a lack of support for the services at issue in this clinical setting.  Therefore, ChemoFx assay performed on 5/08/15 was not likely to have been more effective than other methods of evaluation.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 25-year-old male enrollee has requested authorization and coverage for the LINX Reflux Management System.  The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The U.S. Food and Drug Administration (FDA) approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate GERD and a hiatal hernia less than 3 cm. This patient meets those specific criteria. A recent study comparing the LINX procedure with laparoscopic fundoplication was performed. This was a retrospective study which used propensity matching to compare groups. The authors found that GERD patients had similar control of reflux symptoms after both LINX and fundoplication. The inabilities to belch and vomit were significantly fewer with LINX, along with a significantly lower incidence of severe gas-bloat symptoms (Reynolds, et al). In addition, a five-year cohort data supports the durability of the device. In a group of 85 patients augmentation of the lower esophageal sphincter with a magnetic device provided significant and sustained control of reflux, with minimal side effects or complications (Ganz, et al). Therefore, the request for the LINX Reflux Management System is 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 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 25-year-old male enrollee has requested authorization and coverage for the LINX Reflux Management System.  The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found in this case, the patient presents with non-acid dyspepsia as well as GERD, based on pH recording. The records demonstrate that the patient has benefited to a significant degree from acid suppression treatment to the same extent that his pH study showed correlation of acid reflux events and heartburn. Thus, the patient cannot be considered medically refractory to acid blocker drugs, and does not meet the U.S. Food and Drug Administration (FDA) indication for implantation of the LINX device. In addition, the, implantation of LINX in this clinical setting must be approached with caution given the patients documented complaint of dysphagia. For the reasons provided, the request for the LINX Reflux Management System 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 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 Upheld

Summary Reviewer 3

A 25-year-old male enrollee has requested authorization and coverage for the LINX Reflux Management System.  The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment (Sheu, et al; Ganz). For these reasons, LINX Reflux Management System 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 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 47-year-old male enrollee has requested authorization and coverage for Harvoni.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found according to the most recent 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 limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials.  All told, the requested medication Harvoni is medically indicated for the treatment of this patient.  Therefore, the requested medication is 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 63-year-old female enrollee has requested reimbursement for digital breast tomosynthesis provided on 1/21/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers especially in patients with extremely and heterogeneously dense tissue. Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the examination been done using two-dimensional imaging alone.  Based upon the information set forth above, the services at issue were 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 2


A 63-year-old female enrollee has requested reimbursement for digital breast tomosynthesis provided on 1/21/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this patients case.  According to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  In sum, digital breast tomosynthesis performed on 1/21/16 was 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 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 63-year-old female enrollee has requested reimbursement for digital breast tomosynthesis provided on 1/21/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis performed on 1/21/16 was likely to have been superior over other modalities for evaluating this patient.  Based upon the information set forth above, the services at issue were 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 1

A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/27/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the standard protocol for an intermediate thickness tumor such as in this case does not include a work-up with molecular genetic testing. Although DecisionDx-Melanoma testing has shown results in predicting risk of metastasis, there is no set change in treatment protocol based on the findings. Currently the standard of care includes wide local excision and a sentinel node biopsy and the decision to pursue medical treatment would be based on the results of these tests. There are no clinical studies at this time that show that the results of the molecular testing will make a difference in the treatment or morbidity or mortality of the patient. For the reasons provided, the DecisionDx-Melanoma testing performed on 10/27/16 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 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/27/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cutaneous melanoma. 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. Although DecisionDx Melanoma may be an independent predictor of metastasis risk, there is a lack of peer-reviewed published studies confirming this hypothesis. For this reason, the DecisionDx-Melanoma testing performed on 10/27/16 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 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/27/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma assay should not be used outside of a clinical trial setting. The use of DecisionDx-Melanoma testing is not the standard of care in the treatment of the patients melanoma. Thus, its usage is not expected to impact the patients treatment or health outcome. All told, the DecisionDx-Melanoma testing performed on 10/27/16 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


An 18-year-old female enrollee has requested reimbursement for psychiatric residential treatment from 11/24/14 through 1/08/16.  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 the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a danger to herself or others.  She participated in her treatment plan.  She tolerated her medications without adverse events.  She was learning to contain herself and deal with her emotions.  Her living environment was supportive, and there was no evidence that returning her to the community would have led to a decompensation in her condition.  She had no coexisting medical conditions.  She did not require 24 hour nursing and medical supervision and although she required ongoing psychological and psychiatric treatment, this could have occurred at a lower level of care.  All told, psychiatric residential treatment from 11/24/14 through 1/08/16 was not medically indicated 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 

A 47-year-old male enrollee has requested authorization and coverage for Dupixent (dupilumab). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees atopic dermatitis. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. This patient has a chronic history of moderate to severe atopic dermatitis which has been unresponsive to treatment with numerous medium to ultrapotent topical steroids, topical immunomodulators and intramuscular steroids. Dupixent is a U.S. Food and Drug Administration (FDA) approved injectable biologic for the treatment of moderate to severe atopic dermatitis.  Given that the patient has had a lifelong history of moderate to severe atopic dermatitis and has failed management with topical and systemic steroids as well as topical immune modulators, Dupixent is medically appropriate. The long-term risks of continued use of topical or systemic steroids has been well-established. Thus, Dupixent (dupilumab) is medically necessary for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

The patient is a 55-year-old female with duplex documented right great saphenous vein reflux and a vein measuring greater than 6 mm at the saphenofemoral junction and further down the thigh. She has completed conservative measures and has had previous interventions. The patient has requested authorization and coverage for varicose vein surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. There is sufficient support for the requested services in this clinical setting. Despite prior interventions, this patient remains symptomatic. Additionally, the records document a prior course of conservative treatment. Per the records, her prior treatment included compression hose, elevation, exercise and Motrin. The medical evidence supports the requested services in this patients case. Thus, the requested varicose vein surgery is medically necessary for the treatment of this patient. Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 52-year-old female with a reported history of chronic back pain dating back to 2005.The patient has requested authorization and coverage for cervical spine MRI and thoracic spine MRI. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient. The physician reviewer found that there are two studies currently under question. The first is an MRI of the cervical spine. In the medical records, there is no mention of any signs or symptoms pointing to the neck. In view of this, there is no indication for any imaging of the cervical spine. For the thoracic spine MRI, the records noted that the patient had a T3-4 radiculopathy. Conceivably, she could have a compression fracture or focal arthritic change. Remotely, she could even have a significant lesion, such as a severe fracture or even a mass. While the likelihood of these possibilities is low, an MRI is the best means to pick up a focal abnormality. The presence of radiculopathy is also considered a legitimate indication for an MRI. In conclusion, there is no indication for a cervical spine MRI. However, the thoracic spine MRI could help in management, Therefore, the requested thoracic spine MRI is medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 40-year-old male enrollee has requested reimbursement for emergency room services provided on 1/24/17. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found the patient is a 40-year-old male who presented to the emergency department on 1/24/17 with reports of back pain. He reported low back pain that had commenced two weeks prior. Carrying his daughter on his shoulders had worsened his discomfort. Ibuprofen, rest, and ice had not alleviated his pain. He denied any fever, numbness, tingling, or loss of bowel or bladder control. The patients vital signs included blood pressure of 131/92, respiratory rate of 18, and a temperature of 98.8 F. Mild discomfort in the lumbosacral region was noted without radiation or step-offs. He had a positive straight leg raising and antalgic gait. No obvious sensory or motor deficits were present. The record notes that the patient had good strength of his hip, knee, and ankle dorsi- and plantar flexion. Normal reflexes were present. An x-ray revealed mild degenerative changes with endplate spur formation at L3-4 and mild facet arthropathy at L4-5 and L5-S1. He was treated with intramuscular Toradol and Flexeril. The patient was assessed with back pain and discharged home with improved symptoms. The patient has requested reimbursement for emergency services provided on 1/24/17. At issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with back pain that had commenced two weeks prior. He had not suffered any trauma. He denied any neurologic symptoms. The patient was afebrile with normal vital signs. He had normal motor strength and no sensory deficits. Given that the patients symptoms were not acute in onset or severe, and he had not suffered any trauma, his symptoms do not meet prudent layperson criteria for an emergency medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services provided on 1/24/17 did not meet prudent layperson criteria for emergency care.