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

Summary Reviewer 2


A 68-year-old male enrollee has requested reimbursement for the positron emission tomography (PET) scan performed on 2/3/15. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for evaluation of the enrollees cognitive impairments, neuropsychiatric symptoms and parkinsonian features.  The physician reviewer found that in patients who have rapid cognitive decline or have symptoms that may mimic other neurodegenerative processes, PET scan is indicated to help differentiate between the conditions that are on the differential diagnosis. Molecular imaging with PET offers a broad variety of tools supporting the diagnosis of movement disorders. The more widely applied PET imaging techniques have focused on the assessment of neurotransmitter systems, predominantly the pre- and post-synaptic dopaminergic system. Additionally, PET imaging with fluorodeoxyglucose (18F) has been extensively utilized to assess local synaptic activity in the resting state and to highlight local changes in brain metabolism accompanying changes in neural activity in movement disorders. Given that the clinical documentation submitted for review, the PET scan performed on 2/3/15 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 diagnostic procedure 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 Overturned

Summary Reviewer 3


A 68-year-old male enrollee has requested reimbursement for the positron emission tomography (PET) scan performed on 2/3/15. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for evaluation of the enrollees cognitive impairments, neuropsychiatric symptoms and parkinsonian features. The physician reviewer found that although a PET scan is not indicated for every patient with progressive cognitive symptoms, it is useful and beneficial for a subset of patients suspected to have FTD versus AD. According to Foster and colleagues The addition of FDG-PET [positron emission tomography with 18F fluorodeoxyglucose] to clinical summaries increased diagnostic accuracy and confidence for both AD and FTD. It was particularly helpful when raters were uncertain in their clinical diagnosis. In this case, the patient was documented to have progressive cognitive decline with abnormal neuropsychological testing and no clear etiology determined by traditional testing. In cases such as this, it is essential to obtain the correct diagnosis to implement the proper treatment and avoid unnecessary treatments that may produce significant side effects. A PET scan is a reasonable medical approach to determine diagnosis and implement the proper therapy as AD and FTD are treated with different medical approaches. Therefore, the PET scan performed on 2/3/15 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 diagnostic procedure 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 

A 60-year-old male enrollee has requested reimbursement for thoracic spine magnetic resonance imaging (MRI) performed on 6/27/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees thoracic pain. The physician reviewer found that presently, there are no discrete guidelines for the management and evaluation of thoracic pain. The current practice guidelines are based upon the guidelines for low back pain. According the American College of Radiology appropriateness criteria for the evaluation of back pain, in a patient with sub-acute or chronic back pain who is a surgical candidate with persistent symptoms after four to six weeks of conservative management, MRI is considered usually appropriate. Imaging after conservative treatment could affect patient management if intervention is pursued. MRI can demonstrate disc disease and central canal stenosis among other findings, which may be the cause of the patients symptoms and may prompt intervention. First-line evaluation and treatment of back pain remains conservative, utilizing NSAIDS, physical therapy, as well as activity modification. If the patient is a candidate for intervention, and the pain persists despite four to six weeks of these measures, then MRI imaging may be appropriate. In this case, there is documentation of conservative evaluation and treatment for at least four weeks. Thus, MRI was appropriate as the next diagnostic step. In sum, thoracic spine MRI performed on 6/27/18 was medically necessary for the evaluation of this patient. Therefore, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 21-year-old female enrollee has requested authorization and coverage for placement of a cardiovascular defibrillator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollee who has a family history of early repolarization syndrome (ERS) and an episode of syncope. The physician reviewer found The patient is a 21-year-old female with a family history of early repolarization syndrome (ERS) confirmed by genetic testing demonstrating mutations in the gene encoding for the ATP-sensitive potassium (+) channel. Her parents are heterozygous for genetic variants associated with the condition. The patient has a brother who had an aborted sudden cardiac arrest during exercise and who is homozygous for both variants. The patient has another brother who had syncope and who is heterozygous for both variants.  The brothers have defibrillators in place.  The patient was determined to be homozygous for the same two variants.  In addition the patient has had two episodes of documented unexplained syncope. The treating provider recommended placement of cardiovascular defibrillator. The Health Insurer denied coverage for the implantable defibrillator as investigational for treatment of this patient. The medical literature supports the requested device for patients who have a genetic predisposition to sudden cardiac death, as evidenced by clinical events in first degree relatives and confirmation of shared genetic variants associated with the condition. (Priori, et al). ERS is associated with an increased risk of idiopathic ventricular fibrillation and sudden death (Adler, et al).  Based on the records provided, the patient has a strong family history of ERS with clinic events as well identified shared gene defects associated with the condition. The patient also reported a personal history of unexplained syncope.  In this circumstance of a strong family history of aborted sudden cardiac arrest in first degree family members, symptoms of syncope, and confirmation of shared homozygous genetic variants associated with the condition, placement of a defibrillator is highly effective and considered standard accepted practice in the medical community.  Moreover, the patients personal history of syncope strengthens the likely benefit for defibrillator placement. As such, the placement of cardiovascular defibrillator is likely to be superior to other forms of therapy available for the treatment of this patient. Therefore, for the reasons stated above, the cardiovascular defibrillator is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 21-year-old female enrollee has requested authorization and coverage for placement of a cardiovascular defibrillator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollee who has a family history of early repolarization syndrome (ERS) and an episode of syncope. The physician reviewer found The patient is a 21-year-old female who has experienced two episodes of unexplained syncope in the setting of homozygous genetic markers for early repolarization syndrome (ERS) associated with a risk of sudden cardiac death. She is noted to have two brothers who have implantable cardioverter-defibrillator (ICD) for protection from sudden cardiac death (SCD) in the setting of ERS. One brother experienced an aborted episode of SCD due to ventricular fibrillation which was effectively treated by an ICD. Physical examinations were noted to be unremarkable. There is also a family history of syncope, sudden cardiac death, and genetic defect with the patient being homozygous for ERS in the setting of two episodes of syncope. The treating provider recommended ICD for protection from SCD. The Heath Insurer denied the request for cardiovascular defibrillator as investigational for treatment of this patient. This patient has a strong family history of SCD and has been documented to be homozygous for ERS by genetic testing and poses as a high risk for SCD. The risk stratification of these patients is problematic in that electrophysiology studies were not conclusive and the baseline electrocardiogram did not demonstrate ERS findings, which may be unmasked by exercise. In the review by Zakka and Marwan, patients who demonstrated to be genetically at risk for SCD would benefit from an ICD. While this patient has not been shown to have suffered an episode of SCD as the etiology for her recurrent syncopal episodes and has not been documented to have baseline ECG changes, there is sufficient documentation and supporting data to justify placement of the defibrillator. The placement of an ICD would likely be more beneficial than standard treatment which would consist of watchful waiting and possible implantable loop recorder (ILR) placement. In addition, the patient presents at a high risk for another episode. Moreover, the standard ILR is only capable of documenting, and not treating episodes of malignant arrhythmias. All told, the placement of cardiovascular defibrillator is likely to be more effective than the available standard options for treatment of this patient. Therefore, for the reasons stated above, the cardiovascular defibrillator is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 21-year-old female enrollee has requested authorization and coverage for placement of a cardiovascular defibrillator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollee who has a family history of early repolarization syndrome (ERS) and an episode of syncope. The physician reviewer found The patient is a 21-year-old female who presented to her provider for syncope and ventricular tachycardia. Genetic testing has shown homozygous for genetic abnormality. Family history is positive for syncope due to cardiac arrhythmia and other family members also have implanted defibrillators. The patients diagnosis is early repolarization syndrome (ERS). Implantable cardiac defibrillator (ICD) was recommended by the treating provider. The Health Insurer denied the requested device as investigational/experimental for treatment of this patient. The diagnosis of ERS is an uncommon diagnosis with some uncertainty in the recommended treatment. However, this patient has been symptomatic with syncope and has the documented genetic abnormality. The most recent guidelines from American College of Cardiology and the European Society of Cardiology do not directly make treatment recommendations for this diagnosis. However, ICD is recommended for individuals with long QT syndrome and cardiac syncope, and this condition of ERS is very similar. Majida and colleagues noted that electrophysiological studies (EP studies) do not help differentiate individuals who are at higher risk of sudden death within this diagnosis group, so further EP study would not be helpful. With the documented genetic abnormality, the family history and the symptoms, the requested cardiovascular defibrillator is likely to be more efficacious than the standard treatment available for the treatment of this patient. Therefore, for the reasons stated above, the cardiovascular defibrillator is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 53-year-old female enrollee has requested reimbursement for the Foundation One genetic testing performed on 1/25/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees serous papillary carcinoma. The physician reviewer found that there are many agents with activity against recurrent ovarian cancer (Patch, et al). Recently, it has become important to identify mutations that may be amenable to targeted therapy. Von Hoff and colleagues reported on a study of 86 patients where the progression free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The authors found that the regimen selected by molecular profiling offered a 27% survival advantage. Given this support, the Foundation One test provided on 1/25/17 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 Overturned

Summary Reviewer 2

A 53-year-old female enrollee has requested reimbursement for the Foundation One genetic testing performed on 1/25/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees serous papillary carcinoma. The physician reviewer found that serous papillary carcinoma is a malignant histologic sub-type uterine carcinoma that have a propensity to spread within the peritoneum or by lymphovascular invasion. Standard practice is to initiate systemic therapy with adjuvant intent if all macroscopic disease is removed or systemic with palliative intent if the provider is unable to remove all disease. Current guidelines suggest that there are a number of systemic therapy and hormone therapy options that can be considered. There is limited data regarding the benefit of subsequent treatment for patients who progress despite two prior regimens. Thus, tumor molecular assessment is the only effective means to assess the patients therapeutic options. For these reasons, the Foundation One genetic testing performed on 1/25/17 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 Overturned

Summary Reviewer 3

A 53-year-old female enrollee has requested reimbursement for the Foundation One genetic testing performed on 1/25/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees serous papillary carcinoma. The physician reviewer found that the utility of the Foundation One testing has not been demonstrated to improve patient outcomes as compared to standard testing. According to the National Comprehensive Cancer Network (NCCN), to demonstrate clinical utility of panel genetic testing such as Foundation One, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. The available literature on clinical utility consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. This evidence is not sufficient to make any conclusions on clinical utility. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the Foundation One test provided on 1/25/17 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 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 Overturned

Summary Reviewer 1

The parent of a 14-year-old female enrollee has requested authorization and coverage for lidocaine injection 10 mg and associated inpatient stay. The Health Insurer has denied this request and reported that the requested services and requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that patients with chronic migraine headache are frequently refractory to conventional pharmacotherapy, either prophylactic or abortive in nature. While there have been trials with intranasal lidocaine, which also has rapid systemic absorption, there is a body of literature that supports the use of lidocaine infusion with considerable improvement in the severity of the headache, lessened or absent dependence on other analgesic medication, and most importantly cessation of chronic daily headache for prolonged periods of time. The medical evidence supports the requested services and requested medication in this clinical setting. Therefore, lidocaine injection 10 mg and associated inpatient stay are likely to be superior over other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

The parent of a 14-year-old female enrollee has requested authorization and coverage for lidocaine injection 10 mg and associated inpatient stay. The Health Insurer has denied this request and reported that the requested services and requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested services and requested medication in this clinical setting. A stepwise, exhaustive trial of numerous medications from different classes has been used for both migraine prophylaxis and acute abortive treatment. This patient has tried the new anti-calcitonin gene-related peptide medications, without improvement in her symptoms. She has had several inpatient admissions for infusions of different medications, including sodium valproate, dihydroergotamine, and Thorazine. She has also had multiple injections to the greater occipital nerve, without improvement in her symptoms. There are published studies supporting the use and efficacy of intravenous lidocaine in migraine and chronic daily headache. Due to the potential side effects of this medication, close monitoring in an intensive care unit is required. In sum, lidocaine injection 10 mg and associated inpatient stay are likely to be of greater benefit than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

The parent of a 14-year-old female enrollee has requested authorization and coverage for lidocaine injection 10 mg and associated inpatient stay. The Health Insurer has denied this request and reported that the requested services and requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that Lidocaine infusions have been used in the adult population for years, and more recently have crossed over to the adolescent population with chronic pain. Studies of parenteral lidocaine for refractory chronic pain have demonstrated tolerability and efficacy. Parenteral lidocaine has been studied in adolescent patients with status migraine, and in appropriately chosen patients, has demonstrated both safety and efficacy. This treatment is not intended as a first-line approach to migraine pain. It is reserved for patients who have tried and failed numerous other treatment modalities. This patient has utilized multiple medications, lifestyle changes, complementary therapies and inpatient infusions, all without relief. Thus, lidocaine injection 10 mg and associated inpatient stay are likely to be more effective than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1



A 36-year-old female enrollee has requested reimbursement for infliximab antibody testing performed on 3/30/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the infliximab antibody testing performed on 3/30/15 was not likely to be more effective for this patient than other available options. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear. There are few well controlled clinical trials to confirm that use of the infliximab antibody testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al). At this time it has not been established in the peer-reviewed literature whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Given the above, 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.