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

Summary Reviewer 3


A 20-year-old male enrollee has requested reimbursement for the human T-lymphotropic virus (HTLV) testing performed on 4/25/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees sperm prior to banking. The physician reviewer found that sperm banking is regulated by the U.S. Food and Drug Administration (FDA). A committee opinion states that HTLV testing may be obtained at the discretion of the provider in the appropriate clinical setting. Although HTLV testing would benefit the recipient of the sperm and the embryo, the patient would not receive benefit. Thus, although the FDA recommends testing and the American Society Reproductive Medicine states it is optional, the HTLV testing in this circumstance 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 1
A 47-year-old male enrollee has requested reimbursement for automated evacuation of meibomian glands performed on 2/2/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees meibomian gland dysfunction. The physician reviewer found that the automated evacuation of meibomian glands performed on 2/2/15 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. This procedure utilizes a device that heats the palpebral surface of upper and lower eyelids while simultaneously applying graded pulsatile pressure to the outer eyelid for 12?minutes, thereby expressing the meibomian glands during heating (Friedland, et al). The study results by Finis and colleagues showed that a single thermodynamic treatment is effective in the treatment of meibomian gland dysfunction and that the effects last for at least six months. Although automated evacuation of meibomian glands have promise, there is a lack of evidence in the medical literature supporting that the services at issue were more effective than standard therapy such as hot compresses and lid hygiene. 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 47-year-old male enrollee has requested reimbursement for automated evacuation of meibomian glands performed on 2/2/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees meibomian gland dysfunction. The physician reviewer found that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Meibomian gland dysfunction is one of the underlying components of blepharitis (Bron, et al). There are many treatments to temporarily reduce the annoyance of blepharitis, but there is no lasting cure. LipiFlow is an automated process that warms the eye lids to reduce the viscosity of the glandular secretions, and then mechanically massages the lids to express these secretions (Friedland, et al). Although treatment with LipiFlow may provide some relief, the effect is temporary, frequently wearing off in days or weeks. In addition, the service at issue is not the standard of care and not likely to be more beneficial for treatment of the patients medical condition than any other modalities. 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 47-year-old male enrollee has requested reimbursement for automated evacuation of meibomian glands performed on 2/2/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees meibomian gland dysfunction.
The physician reviewer found that according to Thode and Latkany Meibomian gland (MG) dysfunction (MGD) is a multifactorial, chronic condition of the eyelids, leading to eye irritation, inflammation and ocular surface disease. Initial conservative therapy often includes a combination of warm compresses in addition to baby shampoo or eyelid wipes. There is some evidence in the medical literature that automated evacuation of meibomian glands (LipiFlow) can be therapeutic in select patients. However, LipiFlow is a treatment of last resort in patients whose meibomian glands have not responded to standard treatments (Thode and Latkany; Satjawatcharaphong et al). In this case, there is a lack of documentation supporting that all other treatments had been tried failed. Therefore, one cannot conclude that the use of LipiFlow was clinically indicated or 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 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 1

A 50-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/03/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that 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 to these statistics. This particular melanoma could not be accurately staged, as the thickness could not be determined due to the fact that the tumor had apparently regressed spontaneously prior to biopsy. The features that could be seen included that there was no ulceration and no mitoses. DecisionDx-Melanoma testing is a study of 31 genes in a particular melanoma. It then classifies that melanoma into either Class 1 or 2, with a significant difference in the risk of recurrence at five years between these two classes. Gerami reported on 217 cases, with good correlation in prognosis between the two DecisionDx-Melanoma testing classes in patients who have undergone sentinel node biopsy. Berger and colleagues reported on 156 patients, but the follow-up was not sufficient to determine the real value of the test. It is not clear how the five-year DecisionDx-Melanoma testing data compares to the ten-year Balch data. Most importantly, it has not been shown that DecisionDx-Melanoma testing can be used to make clinical decisions about treatment. Therefore, DecisionDx-Melanoma testing performed on 8/03/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 50-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/03/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had an early stage melanoma. Per the National Comprehensive Cancer Network guidelines, 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, 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. All told, DecisionDx-Melanoma testing performed on 8/03/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 50-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/03/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with a high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing performed on 8/03/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


An 18-year-old male enrollee has requested authorization and coverage for genioplasty sliding osteotomy. 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 osteoplastic genioplasty is a procedure that has been used for the treatment of sleep apnea with limited success. When the mandible is retrusive, usually a Class II malocclusion with an under projecting chin, an argument for sliding osteoplastic genioplasty would be a reasonable consideration. Theoretically, moving the chin forward, or anterior, will advance the tongue base forward and enlarge the hypopharyngeal airway. However, this is not the situation in this case. This patient has an overly projected chin with excessive vertical height and a poorly defined labiomental fold. The mandible is already over-projected. Thus, the osteoplastic genioplasty is being done to reduce the vertical height of the chin, not to advance the chin forward. This is done to improve the long face created by the excessive height of the mandible, and improve the aesthetics of the face by creating a more defined labiomental crease, but it will not improve the patients airway. There is an alternate indication for osteoplastic genioplasty. When performing maxillary advancement, bone grafts may be necessary to stabilize the maxilla. One source of bone is the mandible. If a bone graft is needed and this provides an adequate amount of bone, then a rib or cranial bone graft would not be needed. In this case, the surgeon did not include bone graft in the requested procedures. In sum, genioplasty sliding osteotomy in this clinical setting will not improve tongue position or add to improvement in the airway. As such, the requested services are not medically necessary for treatment of the patients medical condition. Thus, 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 Overturned

Summary Reviewer 




A 45-year-old female enrollee has requested authorization and coverage for L-methylfolate. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who is homozygous for methylene tetrahydrofolate reductase (MTHFR) enzyme deficiency. The physician reviewer found there is sufficient support for the requested medication in this clinical setting.  Folic acid is vitamin B9.  It is converted to L-methylfolate, the active form of the vitamin in the body, by an enzyme, MTHFR.  If individuals lack the ability to convert folic acid, they may be prescribed synthetic L-methylfolate.  It is hypothesized that L-methylfolate may help the body create neurotransmitters such as serotonin, dopamine and norepinephrine, and thus may augment antidepressant medications for those struggling with treatment-resistant depression.  Despite the rather limited data, L-methylfolate is safe and reasonably expected to improve the patients condition in this case.  The patient has trialed many standard therapies for major depressive disorder, to no avail.  Thus, the affective illness can be characterized as treatment-resistant depression.  The patient has a genetic test that demonstrates a defective MTHFR gene which suggests L-methylfolate deficiency.  There are several well-designed studies that demonstrate the benefit of L-methylfolate augmentation.  Further, when considering the favorable safety profile, the potential benefits appear to outweigh the risks of treatment.  Finally, the patient is reportedly in remission on the combination of bupropion and L-methylfolate.  Thus, L-methylfolate 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 Upheld

Summary Reviewer 1


A 64-year-old female enrollee has requested reimbursement for the Decision DX Melanoma assay performed on 6/16/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.   The physician reviewer found that review of the submitted documentation and relevant literature fails to support the services at issue in this clinical setting. This patient has a Stage I melanoma. There is a lack of support in the peer reviewed literature demonstrating the use of gene expression profiling would change the management of treatment for patients with Stage I melanoma. National Comprehensive Cancer Network (NCCN) guidelines state 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 [sentinel lymph node biopsy] SLNB) is not recommended outside of a clinical study (trial). Based on the lack of support in the peer-reviewed literature, the Decision DX Melanoma assay performed on 6/16/15 was not likely to be more beneficial for evaluation of the patients medical condition than other modalities. 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 64-year-old female enrollee has requested reimbursement for the Decision DX Melanoma assay performed on 6/16/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.   The physician reviewer found that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient presents with Stage I melanoma, with no adverse prognostic features. In this clinical setting, adjuvant therapy is only indicated for patients with node positive disease. Further studies are needed to assess Decision DX Melanoma assay and how the results will be incorporated into staging and ultimately treatment. The standard therapy for a Stage I melanoma is wide excision. In addition, the American Joint Committee on Cancer (AJCC) does not recommend Decision DX Melanoma assay in this clinical setting. 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

A 64-year-old female enrollee has requested reimbursement for the Decision DX Melanoma assay performed on 6/16/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.   The physician reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but suggest a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha (Balch, et al). Currently, tshere is a lack of data in the medical literature supporting the use of Decision DX test in this clinical setting. Moreover, there is a lack of support in the peer-reviewed literature demonstrating how best to incorporate Decision DX testing into the treatment algorithm beyond standard staging techniques. Given the lack of support in the medical literature, the Decision DX Melanoma assay performed on 6/16/15 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 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 51-year-old male enrollee has requested reimbursement for residential treatment services provided from 7/17/15 through 9/29/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees substance abuse disorder. The physician reviewer found in sum, the patients records reflect that he was evidencing unstable vital signs, showed poor judgment, and exhibited potentially unsafe behaviors throughout his stay at the RTC. As such, the residential treatment services provided from 7/17/15 through 9/29/15 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


A 62-year-old male enrollee has requested reimbursement for the RT300 functional electrical stimulator (FES) cycle provided on 2/10/16. The Health Insurer has denied this request indicating that the equipment at issue was considered investigational for treatment of the enrollees quadriplegia.   The physician reviewer found the RT300 FES cycle was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The RT300 cycle has not been demonstrated to prevent secondary long-term cardiovascular dysfunction or promote cardiac conditioning. In addition, the RT300 has not been proven to result in changes in muscle strength and volume that lead to clinically significant functional improvement in long-term patient outcomes. The RT300 FES cycle is not reasonably expected to reduce the long-term deficits secondary to this patients injury and assist the patient to maintain and achieve functional capacity in performing daily activities. Baldi and colleagues suggested that neuromuscular electrical stimulation may increase muscle mass in some spinal cord injury patients with disuse atrophy, however, the literature does not demonstrate that this leads to improved health outcomes such as reduced fracture risk from increased bone density. All told, the peer-reviewed medical literature does not support the RT300 FES cycle provided on 2/10/16 as likely to be more beneficial for treatment of this patients medical condition than standard available treatment options. Based upon the information set forth above, the equipment at issue was 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 62-year-old male enrollee has requested reimbursement for the RT300 functional electrical stimulator (FES) cycle provided on 2/10/16. The Health Insurer has denied this request indicating that the equipment at issue was considered investigational for treatment of the enrollees quadriplegia.   The physician reviewer found that currently, there is a paucity of proven significant health or functional benefits of exogenous neurostimulation therapy of paralyzed muscles using FES cycle ergometry for use in this clinical setting. There have been a number of case reports and series providing some preliminary data suggesting possible benefits, but larger studies designed to evaluate the actual clinical efficacy of passive exercise such as FES cycle ergometry in the setting of spinal cord injury are lacking. While repeated bouts of exogenous neurostimulation of paralyzed muscle may potentially retard or reverse muscle atrophy in paralyzed muscle, there is no proven significant health or functional benefit of this achievement in patients with spinal cord injury because the muscle tissue that is gained or spared does not protect against pressure ulcers or provide any other clinically or functionally relevant benefit. Passive cycling may be an option to provide passive range of motion therapy to prevent contractures or mitigate spasticity, but this is considered a custodial use of the device (Reichenfelser, et al). The other purported benefits of passive cycling have not been sufficiently investigated to allow conclusions related to clinically relevant outcomes. To date, the limited available data provide mixed results regarding health measures. Given that the RT300 FES cycle is not active exercise and not an appropriate substitute for active exercise, its use in this patients care was not indicated. Thus, the RT300 FES cycle provided on 2/10/16 was 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 equipment at issue was 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.