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

Summary Reviewer 2

A 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma assay performed on 4/12/18. 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 has an early stage melanoma. The National Comprehensive Cancer Network guidelines state 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 the services at issue were not likely to have altered treatment and surveillance recommendations. In sum, DecisionDx-Melanoma assay performed on 4/12/18 was not likely to have been more effective than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma assay performed on 4/12/18. 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 there is a lack of support for the services at issue in this clinical setting. As the records do not document that the patient underwent a sentinel node procedure, it cannot be determined whether the patient had stage I/II/II disease. The proposed clinical utility of the DecisionDx-Melanoma assay applies to pathologically confirmed stage I/II/III. Therefore, DecisionDx-Melanoma assay was not likely to have been beneficial for this patients medical condition, as it has not been determined that he had the correct stage of disease due to the lack of lymph node staging. Thus, DecisionDx-Melanoma assay performed on 4/12/18 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 48-year-old male enrollee has requested reimbursement for unlisted multianalyte assay with algorithmic analysis performed on 11/25/19. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient has an early stage melanoma. Commercially available gene expression profiling (GEP) tests, such as DecisionDx-Melanoma testing are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear whether these tests provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariable nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. Therefore, unlisted multianalyte assay with algorithmic analysis performed on 11/25/19 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 31-year-old female enrollee has requested reimbursement for the collagen cross links, any method (CPT code 82523) provided on 1/10/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees left ankle pain status De Novo procedure for osteochondral lesion of the medial talar dome. The physician reviewer found that serum or urine collagen crosslinks or biochemical markers are unproven to assess risk of fracture, predict bone loss, or assess response to anti-resorptive therapy. The current medical literature shows there is evidence that standard methods for measuring bone turnover markers are sufficiently sensitive to reliably determine individual treatment responses. There is insufficient evidence from controlled studies that bone turnover marker measurement improve adherence to treatment or improve health outcomes by reducing fracture rate. All told, the collagen cross links, any method (CPT code 82523) provided on 1/10/17 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 service 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 31-year-old female enrollee has requested reimbursement for the collagen cross links, any method (CPT code 82523) provided on 1/10/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees left ankle pain status De Novo procedure for osteochondral lesion of the medial talar dome. The physician reviewer found that the use of collagen cross links and biochemical markers of bone turnover, are unproven and not considered part of the standard of care in this clinical setting. Other testing that was performed in this patients case should have been adequate to rule out a bone formation abnormality. As such, the collagen cross links, any method (CPT code 82523) provided on 1/10/17 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 service 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 31-year-old female enrollee has requested reimbursement for the collagen cross links, any method (CPT code 82523) provided on 1/10/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees left ankle pain status De Novo procedure for osteochondral lesion of the medial talar dome. The physician reviewer found that measurement of serum or urinary collagen crosslinks or other biochemical markers of bone remodeling has not been demonstrated in well designed randomized controlled clinical trials to improve the screening, diagnosis, or management of clinical conditions concerning bone healing and bone turnover. Overall, there is a paucity of data that the clinical value of these markers results in improved health outcomes. Given these findings, the collagen cross links, any method (CPT code 82523) provided on 1/10/17 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 service 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 48-year-old female has requested reimbursement for genotyping for CYP2D6 polymorphism performed on 7/10/14.  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 a lack of evidence supporting the services at issue in this clinical setting.  The National Comprehensive Cancer Network does not recommend routine testing for CYP2D6 genotype in women being considered for tamoxifen therapy.  This issue has been retrospectively examined in a postmenopausal population of women, in which investigators found no difference in outcome according to CYP2D6 genotype.  Moreover, the superior benefit of this screening in premenopausal women has not been established.   Per the medical evidence, the superior efficacy of genotyping for CYP2D6 polymorphism performed on 7/10/14 has not been demonstrated.  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 48-year-old female has requested reimbursement for genotyping for CYP2D6 polymorphism performed on 7/10/14.  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 since tamoxifen must be metabolized to a metabolite to be active, there has been an interest in evaluating the impact of the enzymes that affect this metabolism to an active state.  CYP2D6 is involved in the conversion of tamoxifen to endoxifen, its most active metabolite.  There have been multiple studies attempting to correlate CYP2D6 genotype to the efficacy of tamoxifen.  The overall conclusion is that there is no clear-cut benefit to the use of this genotyping in determining whether tamoxifen should be given to an individual patient.  There is insufficient data in either premenopausal or postmenopausal women to establish that CYP2D6 genotyping would be beneficial.  Therefore, genotyping for CYP2D6 polymorphism performed on 7/10/14 was not likely to have been of greater benefit 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 3


A 48-year-old female has requested reimbursement for genotyping for CYP2D6 polymorphism performed on 7/10/14.  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 the patients with hormone receptor positive breast cancer usually receive some pharmacologic therapy to inhibit the estrogen induced growth of the cancer.  The interventions differ for patients that are premenopausal and postmenopausal.  Tamoxifen is the preferred agent in premenopausal women whereas aromatase inhibitors are preferred in postmenopausal patients.  There is sufficient support for the services at issue in this clinical setting.  Saladores and colleagues performed a study of 587 premenopausal women and analyzed CYP2D6 genotypes and found that increased CYP2D6 activity correlated with improved disease-free survival.  In the event that tamoxifen was not a suitable anti-estrogen therapy for this patient, there were alternatives.  Based on the current medical literature, CYP2D6 genotyping is supported especially in premenopausal patients.  Thus, genotyping for CYP2D6 polymorphism performed on 7/10/14 was likely to have been more efficacious than other options 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 15-year-old female enrollee has requested reimbursement for inpatient care from 4/13/17 through 4/19/17. 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 that the submitted documentation supports the medical necessity of the services at issue.  The medical records indicate that this patient continued to exhibit the same acuity level of thoughts of self-harm and suicide that were the reason for her admission.  Transfer to residential treatment center level of care was not an option as the residential treatment center professionals felt she was still too acute and not ready for this transfer.  Based on the records, continued treatment at the inpatient level of care was indicated.  Her history shows that a premature discharge would result in a quick relapse and readmission.  All told, inpatient care from 4/13/17 through 4/19/17 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 54-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 hepatitis C virus. The physician reviewer found according to the American Association for the Study of Liver Diseases (AASLD) and 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. This applies regardless of fibrosis stage or viral load. Per guidelines, Harvoni is first-line therapy for treatment-naive genotype 1 patients. Non-cirrhotic patients with a viral load below six million IU/mL can be treated with Harvoni for eight weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). For these reasons, Harvoni should be approved as medically necessary based on national guidelines. For the reasons provided, 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 45-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma Assay provided on 12/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the standard protocol based on National Comprehensive Cancer Network (NCCN) guidelines for an intermediate thickness tumor does not include a work-up with molecular genetic testing. Currently, the protocol includes wide local excision and sentinel node biopsy. The decision to pursue medical treatment is based on the results of these tests. There is a lack of clinical studies that show that the results of molecular testing results in improved patient health outcomes when compared to standard evaluation. All told, the DecisionDx-Melanoma Assay provided on 12/6/17 was not medically necessary for evaluation of this patients melanoma. Based on the foregoing discussion, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 54-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees prostate cancer. The physician reviewer found that currently, there is insufficient clinical data to discern whether treatment with proton beam radiation therapy offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Sheets and colleagues evaluated the comparative effectiveness of intensity-modulated radiation therapy (IMRT), proton beam radiation therapy, and conformal radiation therapy for prostate cancer. In the comparison between IMRT and proton beam radiation therapy, IMRT patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities between IMRT and proton therapy. The National Comprehensive Cancer Network guidelines indicate that no clear benefit of proton beam radiation therapy has been demonstrated over standard treatment with photons and IMRT technique. Therefore, the requested proton beam radiation therapy is not medically necessary for the treatment of this patient. Therefore, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 37-year-old male enrollee has requested reimbursement for an ultrasound provided on 4/05/18. 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 liver fibrosis is an important prognostic factor in patients with chronic hepatitis B, and assessment of the stage of liver fibrosis is important in management. Ultrasound with elastography offers a noninvasive alternative to biopsy for the assessment of liver fibrosis, with comparable diagnostic accuracy, but also can identify patients with subclinical cirrhosis who are at increased risk of developing hepatocellular carcinoma, even when cirrhosis is not clinically apparent. Elastography is a noninvasive alternative to liver biopsy for this assessment, and avoids the invasiveness, risk of complications, and sampling error associated with liver biopsy. The American Gastroenterological Association (AGA) Institute guideline for elastography states, In patients with chronic hepatitis B, the AGA suggests vibration-controlled transient elastography rather than other nonproprietary noninvasive serum tests to detect cirrhosis. By avoiding the complications of liver biopsy, and allowing for appropriate management of chronic hepatitis B (which differs depending on whether cirrhosis is present), elastography can result in improved health outcomes. For these reasons, ultrasound with elastography was medically indicated for the management of this patients chronic hepatitis B. Therefore, the ultrasound with elastography performed on 4/05/18 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 30-year-old male enrollee has requested reimbursement for substance use residential treatment provided from 7/04/18 through 7/20/18. 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 that the submitted documentation supports the medical necessity of a portion of the services at issue. The patients abuse of alcohol was impairing his daily routine and contributing to significant impairment across multiple domains of functionality. As such, specialty care was indicated. However, the patient completed an uncomplicated detoxification.  He was maintaining sobriety and was motivated for recovery. His girlfriend was supportive. He had safe housing. Despite his comorbid obsessive-compulsive disorder, the patient did not have a psychiatric condition or medical illness that required placement at the residential level of care. Further, the patient had no history of chemical dependency treatment, such as sponsored community programming, outpatient counseling, anti-craving medication, intensive outpatient services, partial hospitalization or placement in a sober living environment.  This is significant in this case for two reasons. First, modern psychiatric practice favors treatment in the community, as outcome measures and therapeutic gains are optimized in this environment. Second, there was no evidence to suggest that similarly comprehensive, evidence-based services provided a less restrictive treatment setting for this stable, motivated and otherwise healthy patient would have been insufficient or inadequate at the time. With that said, discharge on a federal holiday would have incurred a needless gap in treatment and thus would have been inappropriate. The extra day also afforded opportunity to address his severe craving, as it appears that acamprosate was added the following day. On 7/05/18, the patients craving was mild. There was no mention of medication intolerability or non-adherence. His appearance was appropriate, and he had no impairment in memory, concentration or thought processing. In sum, the patient had improved with the treatment intervention. He was autonomous and was maintaining motivation for sobriety. Further, he had not failed a less restrictive treatment course during the episode of illness. As such, the substance abuse residential treatment services at issue were no longer medically necessary as of 7/05/18. Thus, substance use residential treatment provided on 7/04/18 was medically necessary, but not thereafter. Therefore, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 69-year-old female enrollee has requested reimbursement for lipoprotein (a) testing performed on 2/09/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. At issue is whether the services at issue were likely to have been more beneficial for evaluation of the enrolleeas condition than any available standard therapy. The physician reviewer found that there is a lack of accepted clinical studies demonstrating that strategies to correct the residual risk potentially identified by novel lipoprotein testing, such as the advanced lipoprotein analysis performed in this patientas case, will further reduce cardiac risk. It remains unclear from the current literature that such testing adds significant actionable information to what is already known from a fasting lipid panel, despite significant cost. There is insufficient evidence to support the use of advanced lipoprotein analysis in clinical practice, particularly in individuals at low risk such as the patient. In this case, the records document a recent coronary calcium score of zero. Therefore, lipoprotein (a) testing performed on 2/09/21 was not likely to have been more beneficial than other available methods of evaluating this patient.