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

Summary Reviewer 


The parent of a 14-year-old male enrollee has requested reimbursement for residential mental health services provided from 2/8/16 through 7/7/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found that per the documentation, the services provided for the RTC included individual therapy once a week, group therapy five times a week, and family therapy once a week. However, the same services could have been provided in a less restrictive treatment environment. The patient did not require 24-hour supervision. He did not have any homicidal or suicidal ideation, there was no evidence that he was a danger to himself or others, and the patient was medically stable. It is noted that during the residential stay, there were few medication changes and his parent consulted with the patients outpatient psychiatrist for all medication changes. The patient could have been treated by the outpatient psychiatrist for any medication changes. Due to the patients autism spectrum disorder, it is likely that his impulsivity will remain a consistent symptom. Prior RTC care did not report that they made much improvement with the patients impulsivity and inappropriate behavior. The expectation as noted in the documentation was that there would be minimal improvement with the patients impulsivity and inappropriate behavior. Therefore, the RTC mental health services provided from 2/8/16 through 7/7/16 were not medically necessary as there was not a reasonable expectation that RTC treatment services would improve the patients problems. Based on the available records, 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 66-year-old male enrollee has requested authorization and coverage for Viagra 100mg tablets. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees erectile dysfunction The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Both Viagra and Levitra are phosphodiesterase inhibitors which are used to treat erectile dysfunction.  Per the medical evidence, both drugs have a similar mechanism of action and pharmacokinetics.  The current medical literature does not support significant differences in efficacy between the two medications.  In this patients case, treatment with Levitra is medically appropriate.  All told, Viagra 100mg tablets are not medically indicated for the treatment of this patient.  Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be 
upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 52-year-old female enrollee has requested authorization and coverage for gene test (gene expression profiling) performed on 9/20/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has been diagnosed with cutaneous melanoma. The physician reviewer found that there is a lack of support in the medical literature for the services at issue in this patients case. The test claims to determine risk of recurrence for early melanoma. However, there is a lack of data to support using adjuvant therapy in similar patients based on risk of recurrence. Adjuvant therapy is based on stage and not on the risk of recurrence as determined by this test. Moreover, the literature does not support a therapeutic advantage of this test over the standard options since this test is not designed to change or alter therapy nor alter surveillance regardless of risk. Furthermore, prospective randomized data for determination of recurrence is lacking in this test. All told, the gene test (gene expression profiling) performed on 9/20/16 was not likely to have been more beneficial than the established alternatives available for the evaluation of this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2
A 52-year-old female enrollee has requested authorization and coverage for gene test (gene expression profiling) performed on 9/20/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has been diagnosed with cutaneous melanoma. The physician reviewer found that a commercial gene expression profile test (DecisionDX melanoma) has been developed in patients with stage I and II cutaneous melanoma. However, there are no definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials according to published data available. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate benign from malignant neoplasms, or melanomas at low versus high risk for metastasis, routine (baseline) genetic testing of primary cutaneous melanomas (before or following SLNB) is not recommended outside of a clinical study (trial). The gene test (gene expression profiling) performed on 9/20/16 was not likely to have been of greater benefit than available standard therapy for the evaluation of this patients medical condition. 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 3A 52-year-old female enrollee has requested authorization and coverage for gene test (gene expression profiling) performed on 9/20/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has been diagnosed with cutaneous melanoma. The physician reviewer found that DecisionDX melanoma is a commercial gene expression profile test, which has been developed in patients with local (stage I and II) or locoregional (stage III) cutaneous melanoma. The most recent assessment was to determine the impact on clinical practice and therefore did not or was not able to discuss the impact on patient outcome. Version 1.2017 of  the National Comprehensive Cancer Network guidelines indicate that for stage II melanoma, that wide excision be pursued with sentinel lymph node evaluation if the tumor is greater than 0.75mm thick. For stage IA, after resection observation is recommended whereas for stage IIB or IIC, interferon alpha should also be considered. There are no current recommendations to undergo genomic or proteomic analysis to assess risk or assess benefit of adjuvant therapy. According to the current guidelines, this data is not definitive. It is unclear if the addition of DecisionDX melanoma to this patients treatment options would have improved her overall care plan since the role in clinical care is still under investigation. As such, the gene test (gene expression profiling) performed on 9/20/16 was not likely to have been superior to other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 20-year-old male enrollee has requested reimbursement for residential treatment services provided from 3/22/18 through 3/30/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) provides a framework for determining the appropriate level of care in patients with mental health treatment needs. With regard to risk of harm, the records support a score of 3. The patient had a history of chronic impulsive suicidal/homicidal behavior or threats, but his current expressions did not represent significant change from usual behavior. In terms of functional status, the records support a score of 3. The patient had moderate impairment, due to conflicted and troubled relationships and inability to continue in school. With regard to medical, addictive, and psychiatric comorbidity, the records support a score of 3. The patient had significant comorbidity, due to co-occurrence of traumatic brain injury, substance use disorder, and mood symptoms. In terms of level of stress of the recovery environment, the records support a score of 3 due to strained relationship with parents, multiple recent transitions, and recent homelessness. With regard to level of support of the recovery environment, the records support a score of 4 due to the patients refusal to participate in treatment and accept support offered by his parents. In terms of treatment and recovery history, the records support a score of 3. The patient had moderate or equivocal response to treatment. With regard to engagement and recovery status, the records support a score of 4. The patient had minimal engagement and recovery, due to reluctance to engage in or complete residential programs, lack of desire to change behavior, and failure to accept responsibility for his own recovery. Thus, the patient has a total score of 23. The recommended level of care is medically monitored residential services. Given the patients impulsivity and limited coping skills, poor insight and judgment, a residential level of care was appropriate for him at the time of his admission and treatment. Therefore, residential treatment provided from 3/22/18 through 3/30/18 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


An 86-year-old male enrollee has requested authorization and coverage for Sovaldi and Daklinza. The Health Insurer has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines state that patients with cirrhosis are high priority for treatment. According to the guidelines, this patient is interferon-ineligible due to thrombocytopenia. The guidelines recommend that cirrhotic treatment-naive patients with genotype 3 hepatitis C should be treated with Sovaldi and Daklinza (with or without ribavirin) for 24 weeks. This is based partially on the results of the ALLY-3 study, which demonstrated poor cure rates (only 58%) after 12 weeks of therapy (Nelson, et al). For patients with renal failure, the guidelines cite data showing that daclatasvir is an appropriate medication due to lack of substantial renal excretion (Nelson, et al). Data supporting the safety and efficacy of full-dose (400 mg) daily sofosbuvir in end-stage renal disease or hemodialysis with genotype 1a hepatitis C has been published (Nazario, et al). In addition, the guidelines cite study data reporting that delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, the requested treatment with Daklinza and Sovaldi is medically necessary for the treatment of this patients hepatitis C infection. Therefore, the requested medications 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 



A 62-year-old female enrollee has requested authorization and coverage for Repatha sureclick 140 mg/mL. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who has a history of coronary heart disease. The physician reviewer found that the documentation provided supports the medical necessity for the requested medication. Based on the records, the patient has known coronary disease and severely elevated LDL, even while on statin therapy. She also has documented intolerance to multiple statin medications including atorvastatin, rosuvastatin, simvastatin and Vytorin. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 inhibitor approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. Since this patient has documented intolerance to several high intensity statin medications, even at low doses, as well as some moderate intensity statins, it is unlikely that any tolerable statin would be sufficient to lower her LDL without requiring additional LDL lowering medication such as Repatha. In this clinical setting, Repatha has been shown to improve cardiac outcome. As such, the Repatha sureclick 140 mg/mL is medically necessary for the treatment of this patients medical condition. Therefore, for the reasons stated above, 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 Upheld

Summary Reviewer 

A 61-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/02/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation 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 had an early stage melanoma. The National Comprehensive Cancer Network guidelines states while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. This test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy. Therefore, DecisionDx-Melanoma test performed on 10/02/18 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 55-year-old male has requested reimbursement for high-intensity focused ultrasound performed on 8/14/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that high-intensity focused ultrasound has increasingly been used for treatment of localized prostate cancer within the last decade. It has the theoretical potential of decreasing gastrointestinal, genitourinary and sexual toxicity. Potential candidates are patients with low to moderate risk prostate cancer. The available literature mainly consists of prospective case series and retrospective studies showing short to intermediate term outcomes for localized prostate cancer. There is a lack of controlled trials available for analysis, and a lack of long-term survival data is available. There are no validated biochemical and surrogate end-point for cure. The National Comprehensive Cancer Network indicates that further study is warranted. The current evidence has not established the superior efficacy of the services at issue. Therefore, high-intensity focused ultrasound performed on 8/14/17 was not likely to have been of greater benefit than other treatment options. 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 Upheld

Summary Reviewer 2

A 55-year-old male has requested reimbursement for high-intensity focused ultrasound performed on 8/14/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that high-intensity focused ultrasound is an evolving technology in the prostate cancer treatment armamentarium. While the minimally invasive nature makes high-intensity focused ultrasound ablation a readily accessible tool, its role in initial therapy of moderate risk disease as monotherapy shows no benefit and potential risk over standard treatment protocols at this time. In sum, high-intensity focused ultrasound performed on 8/14/17 was not likely to have been of greater benefit than other treatment options. 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 Upheld

Summary Reviewer 3

A 55-year-old male has requested reimbursement for high-intensity focused ultrasound performed on 8/14/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that high-intensity focused ultrasound therapy for prostate cancer is a relatively new procedure. The U.S. Food and Drug Administration (FDA) has approved this procedure to be safe for the treatment of prostate ablation. However, there is no specific indication for the treatment of prostate cancer. The safety and efficacy of this treatment is currently being evaluated. The medical evidence has not demonstrated that this form of treatment is superior to conventional treatment options. Thus, high-intensity focused ultrasound performed on 8/14/17 was not likely to have been of greater benefit than other treatment options. 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 51-year-old female with a long history of obsessive-compulsive disorder, major depressive disorder, generalized anxiety disorder, insomnia related to obsessive-compulsive disorder and tardive dyskinesia that is the result of previous medications used to treat her obsessive-compulsive disorder. Since 2017, treatment for her significantly worsening obsessive-compulsive disorder symptoms have included duloxetine, Lexapro, mirtazapine, paroxetine, propranolol, sertraline and venlafaxine. Antidepressant treatments made her feel worse and increased her anxiety. Gabapentin was not effective. The records noted that Abilify was not effective. Latuda was effective but caused tardive dyskinesia. The records document significant functional decline, including significant anhedonia, inability to get out of bed, and difficulty with sleep. The patient was started on a trial of Nuedexta, and her obsessive-compulsive disorder and depression were significantly ameliorated. She has requested authorization and coverage for Nuedexta 20-10 mg capsules. The Health Insurer has denied this request and reported that the requested medication is 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 submitted records support the medical necessity of the requested medication. Kadriu and colleagues noted that, An open label, one-arm trial of 20 patients with treatment resistant depression who received oral doses of Nuedexta (45 mg and 10 mg, respectively) every 12 hours found that, after 10 weeks, 45% of subjects had experienced remission and 35% had experienced response. The paper by Henter and colleagues highlighted the evidence supporting the antidepressant effects of various glutamatergic modulators such as Nuedexta. The records document debilitating obsessive-compulsive disorder and depression, significant anhedonia and loss of ability to function. The patient was at risk for inpatient psychiatric admission for her severe symptoms and depression prior to her trial of Nuedexta. The documentation indicates that the patient has treatment resistant depression in addition to her treatment refractory obsessive-compulsive disorder. The use of Nuedexta led to clinically significant improvement in her function, when previous first-line treatments had failed, and in fact, had caused her anxiety to worsen. Therefore, Nuedexta 20-10 mg capsules are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 39-year-old male enrollee has requested authorization and coverage for corticotropin (H.P. Acthar Gel) injections, up to 40 units. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the records fail to demonstrate the superior efficacy of the requested medication in this clinical setting. There is a lack of objective information, including physical examination, radiographs and confirmatory laboratory definitive studies, to establish a diagnosis of rheumatoid arthritis. The patient has features of various conditions. He has also not exhausted other treatment options, even if a diagnosis of rheumatoid arthritis has been established. The medical evidence supports the use of methotrexate or combination disease-modifying antirheumatic drug (DMARD) therapy, such as triple therapy with methotrexate, Plaquenil and sulfasalazine, unless contraindicated. A patient who fails DMARD therapy for rheumatoid arthritis is then a candidate for anti-tumor necrosis factor or other biologic therapies. This patient has already tried and failed two different steroids, including prednisone and Rayos. There is inadequate literature indicating that H.P. Acthar Gel is superior to these therapies in terms of efficacy or safety. Therefore, corticotropin (H.P. Acthar Gel) injections, up to 40 units is not likely to be more beneficial than other available treatment options.