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

Summary Reviewer 


A 38-year-old male enrollee has requested reimbursement for a second full-night polysomnography to titrate continuous positive airway pressure performed on 11/12/14. The Health Plan has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient had clinically significant obstructive sleep apnea that was documented within two hours of the start of the sleep study on 9/24/14.  Thus, a split night study with continuous positive airway pressure titration during the same study would have been appropriate.  The purpose of a continuous positive airway pressure titration study is to document the optimal setting of continuous positive airway pressure for patients who meet criteria for continuous positive airway pressure treatment.  The continuous positive airway pressure titration study on 11/12/14 did not result in an optimal continuous positive airway pressure setting, and the result of that study was placement on an auto-titrate continuous positive airway pressure machine within an interval.  There is a lack of support for the services at issue in this clinical setting.  All told, the second full-night polysomnography to titrate continuous positive airway pressure performed on 11/12/14 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 33-year-old male enrollee has requested reimbursement for Prometheus Anser ADA diagnostic testing performed on 5/19/14.  The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the patient was placed on Humira after the identification of a clinical and mucosal relapse while on Cimzia. In addition to 6-MP the patient was placed on an escalated dose of Humira. The patient began to show clinical improvement. There is a lack of controlled data concerning the testing for antibodies or adalimumab levels in this clinical scenario. There is a lack of established data indicating what drug level to target with adalimumab in the setting of an ileocolonic resection to prevent relapse. Given the lack of guidance in the peer-reviewed literature of when to test, how often to test, what to look for, and what to do with the results, the testing at issue was not likely to be more beneficial than other modalities. 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 33-year-old male enrollee has requested reimbursement for Prometheus Anser ADA diagnostic testing performed on 5/19/14.  The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the Prometheus Anser ADA test is a quantitative measurement of serum adalimumab and anti-ADA antibodies. Some evidence exists that low serum levels of ADA or the presence of ADA antibodies have an adverse effect on the clinical outcome of a patients response to treatment. There are few well controlled clinical trials to confirm that use of the Anser ADA test leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al). Moreover, in patients with IBD who lose response to ADA, clinical improvement may occur upon intensification of ADA therapy, irrespective of ADA serum concentration or presence of anti-ADA antibodies (Steenholdt, et al). As such, the clinical utility of measuring drug antibody concentrations is on a case-by-case basis. Based on the clinical documentation submitted for review, it has not been established how this patients specific management would change based on test results. In addition, there are technical factors relating to the use of different assay methods across studies. It has not yet been established whether the use of threshold levels aids in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established, such as in this case. For the reasons provided, the Prometheus Anser ADA diagnostic testing performed on 5/19/14 was not more beneficial for treatment of the patients medical condition than conventional treatment strategies. 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 33-year-old male enrollee has requested reimbursement for Prometheus Anser ADA diagnostic testing performed on 5/19/14.  The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees Crohns disease. The physician reviewer found in this case, the patient has Crohns disease and failed treatment with Cimzia and was switched to Humira. The patient had a better response to a higher dose. Hence, there was consideration for Humira failure or development of antibodies and consideration was being entertained to potentially switch to yet another biologic versus maintenance on a higher dose of Humira. To better guide the management, an ADA test was performed. Due to the multitude of management options once a patient has no response to Humira and the fact that Humira has a wide array of adverse effects, it is important for the treating provider to have a roadmap of the nature of the patients clinical course. ADA testing provides important and significant management implications, and was clinically indicated in this case given the suspicion for potential antibodies or lack of response. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 16-year-old male who underwent surgery on 7/02/19 for management of recurrent dislocation of patella with medial patellofemoral ligament tear, and associated chondromalacia and loose bodies. The procedures included left knee arthroscopy with patellofemoral chondroplasty, excision of loose bodies, tibial osteotomy and patellofemoral ligament reconstruction with allograft. The physician reviewer found that intermittent pneumatic compression is now a widely used therapy for the prophylaxis of deep vein thrombosis and pulmonary embolism, particularly after major surgical procedures on the lower extremities with prolonged immobilization. In general, the device sequence is composed of sequential compression and deflation. Typically, veins are considered to be emptied during the compression phase and refilled during the deflation phase. The device may be supplemented with pharmacotherapy for optimum deep vein thrombosis prophylaxis. In this case, the patient was not able to ambulate for almost nine weeks, and there was a clear need for deep vein thrombosis prophylaxis. As such, the intermittent limb compression device was medically appropriate. Therefore, the intermittent limb compression device provided on 7/02/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 19-year-old female enrollee has requested reimbursement for mental health residential treatment provided from 8/1/13 through 9/26/13. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the mental health residential treatment provided from 8/1/13 through 9/26/13 were medically necessary for treatment of the patients medical condition. The documentation submitted for review supports the residential placement. The patient presents with multiple diagnoses including depressive disorder, autism spectrum disorder, attention-deficit/hyperactivity disorder and substance abuse. According to Mayes and colleagues Comorbid psychological problems most highly predictive of ideation or attempts were depression, behavior problems, and teased. Almost half of children with these problems had suicide ideation or attempts. The patient had recently been hospitalized due to an overdose of Xanax. The treatment at issue was medically necessary to assist the patient with handling life stressors in the context of autism spectrum disorder. Thus, the residential mental health services at issue were medically necessary for treatment of the patients behavioral health condition. Therefore, the services at issue were 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 49-year-old transgender female enrollee has requested reimbursement for facial feminization procedure provided on 3/26/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. This patient has been diagnosed with gender dysphoria, and the records noted social anxiety and depression. The records documented distress related to masculine facial features as well as distress regarding being perceived as male by others. For patients with gender dysphoria, facial feminization surgery is medically necessary in the setting of clinically significant distress or functional impairment. World Professional Association for Transgender Health (WPATH) criteria for surgery state that surgical procedures for patients with gender dysphoria may include augmentation mammoplasty, genital surgery and other interventions, such as facial feminization surgery, liposuction, lipofilling and thyroid cartilage reduction. Thus, the current medical evidence supports the services at issue in this clinical setting. In sum, facial feminization procedure provided on 3/26/18 was medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


The patient is a 59-year-old female who was diagnosed with malignant melanoma in February 2016. The records noted Breslow thickness of 1.28 mm, Clark level IV. Per the pathology report, the margins of excision were free of melanoma. The patient has requested reimbursement for gene testing performed on 5/12/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  There is a lack of support for the DecisionDx-Melanoma testing performed in this case. The results of this testing were not likely to have changed treatment decisions. There is a lack of evidence from the literature that tailored follow-up according to the results of this testing has an impact on long-term outcomes. Therefore, the superior efficacy of gene testing performed on 5/12/16 has not been established. 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

The patient is a 59-year-old female who was diagnosed with a cutaneous melanoma on her left chest wall in February 2016. At that time, she was found to have a non-ulcerating melanoma with Breslow thickness of 1.28 mm, Clark level IV. The patient has requested reimbursement for gene testing performed on 5/12/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. The prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add a bit more to these statistics. DecisionDx-Melanoma assay is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based upon the risk of metastasis. Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification in patients undergoing sentinel node sampling. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year data of Balch. Most importantly, it is not clear if the assay can be used to make clinical decisions. Thus, gene testing performed on 5/12/16 was not 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 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

The patient is a 59-year-old female with a malignant melanoma of the left lateral chest. Pathology showed Breslow thickness of 1.28 mm, Clark level IV. The margins of excision were free of melanoma. Molecular profiling with DecisionDx-Melanoma testing was performed on 5/12/16. The patient has requested reimbursement for gene testing performed on 5/12/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  This patient had an early stage melanoma. The National Comprehensive Cancer Network guideline 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. The results of this testing are not likely to alter treatment and surveillance recommendations. Thus, gene testing performed on 5/12/16 was not likely to have been more effective than 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 40-year-old female enrollee has requested reimbursement for Decision Dx melanoma gene assay performed on 10/15/15. The Health Plan has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk of recurrence in cutaneous melanoma. The physician reviewer found the patient is a 40-year-old female who had a malignant melanoma excised from the skin of the mid lower back. A surgical pathology report noted a diagnosis of malignant melanoma, superficial spreading type with a Breslow thickness of 0.81 mm, Clark level II, area of possible regression, and no evidence of satellitosis. The tumor was noted to be mainly amelanotic. Decision Dx testing revealed Class 1A molecular signature associated with a low risk of recurrence within five years. The patient is requesting reimbursement for Decision Dx melanoma gene assay performed on 10/15/15. The Health Insurer has denied this request as investigational.The testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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 patients melanoma performed with Decision Dx melanoma, the tumor was classified as Class 1 with a low risk of near-term (within five years) metastatic disease, such as 97% metastasis free rate. Although Decision Dx melanoma may be an independent predictor of metastasis risk, there is a lack of peer-reviewed published studies confirming this hypothesis. Therefore, Decision Dx melanoma 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 40-year-old female enrollee has requested reimbursement for Decision Dx melanoma gene assay performed on 10/15/15. The Health Plan has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk of recurrence in cutaneous melanoma. The physician reviewer found that in general, Decision Dx test is not the standard of care for evaluation of melanoma. In this case the patient presented with a thin melanoma of 0.81 mm with poor prognostic compounding factors of ulceration, mitoses, and regression seen on pathology. Typically, when a melanoma is thin, no further testing is required as the risk of spread is low.  However, when a tumor shows mitoses and ulceration it can mean an aggressive histology and further testing like a sentinel lymph node biopsy (SNLB) can be indicated. A SNLB is an invasive procedure and does not provide as much information about risk of tumor metastasis as the Decision Dx test. Therefore, testing was medically reasonable for this patient with a thin melanoma and multiple unique features. All told, the Decision Dx melanoma gene assay performed on 10/15/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 40-year-old female enrollee has requested reimbursement for Decision Dx melanoma gene assay performed on 10/15/15. The Health Plan has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk of recurrence in cutaneous melanoma. The physician reviewer found the Decision Dx melanoma gene assay performed on 10/15/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient was diagnosed with melanoma, Breslow depth 0.81 mm located on the mid lower back. Decision Dx gene testing assays gene expression in the tumor to determine the risk of metastatic disease in the following five years. The use of this testing is not considered to be standard of care. The use of Decision Dx Melanoma testing is not recommended outside of clinical trials according to the National Comprehensive Cancer Network (NCCN) guidelines for the diagnosis and treatment of melanoma. Given that this testing is not the standard of care, 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 30-year-old male enrollee has requested reimbursement for partial hospitalization program (PHP) chemical dependency services provided from 11/24/15 through 12/8/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse and bipolar disorder.   The physician reviewer found that this patients records do not include an admitting psychiatric or psychosocial evaluation with description of the patients social and sober support. In addition, there is no mental status examination or urine drug screening. On 12/3/15, the provider discontinued Abilify, leaving him on Seroquel and Paxil 37.5 mg. The records suggest the patient was psychiatrically stable as group therapy notes state that he was able to participate, concentrate, and maintain appropriate behavior, and there was no indication of medical instability. Overall, there is limited information regarding patients substance abuse or bipolar diagnoses. According to the American Psychiatric Association (APA) guidelines, the PHP chemical dependency services provided from 11/24/15 through 12/8/15 were not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, 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 59-year-old female enrollee has requested authorization and coverage for Prolia (denosumab) injections. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees osteoporosis. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. Osteoporosis is an increasingly widespread condition. Fractures are the most dangerous aspect of osteoporosis. Fractures can lead to acute and chronic pain. A newer medication, denosumab (Prolia), is a fully human monoclonal antibody which has been approved for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone. Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapy.  This patient is unable to tolerate Reclast therapy. The requested medication is medically appropriate in this clinical setting. Thus, Prolia (denosumab) injections are 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.