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

Summary Reviewer 2


A 45-year-old male enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees asthma. The physician reviewer found there is sufficient medical support for the requested procedure in this patients case.  Clinical data demonstrates the short and long term benefits of bronchial thermoplasty for patients with severe asthma. The three initial trials of bronchial thermoplasty have demonstrated improved symptom control after the procedure was completed. Per the submitted records, this patient is unable to tolerate steroids (inhaled or otherwise). Also, the patient has undergone the evaluation and management of several alternative diagnoses (allergic disease, vocal cord dysfunction and reflux). Given the patients inability to tolerate an ideal medication regimen for his asthma, bronchial thermoplasty is an effective intervention. Thus, the requested procedure is an appropriate next step in management and treatment of the patients symptoms. As such, bronchial thermoplasty is likely to be superior over any available standard therapy for treatment of the patients medical condition. Based upon the information set forth above, the requested procedure 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 Upheld

Summary Reviewer 3


A 45-year-old male enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees asthma. The physician reviewer found that guidelines for asthma treatment recommend inhaled steroids as first line of therapy for patients with persistent asthma. The patients provider recommends bronchial thermoplasty because the patient has not been able to tolerate standard therapies to treat his medical condition. Moreover, per the records, inhaled steroids may trigger the patients depression. However, studies which demonstrate a link between depression and the use of inhaled steroids are lacking. The amount of steroids which gets into the circulation is very small, and it is unlikely to trigger depression. Also, there are methods to decrease intestinal absorption of inhaled steroids. In sum, this patient has not demonstrated that he has tried and failed standard medications recommended in the asthma guidelines. For these reasons, the requested procedure is not likely to be more efficacious for treatment of this patients medical condition than other alternatives. Based upon the information set forth above, the requested procedure is 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 51-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma Assay (CPT code 84999 - unlisted chemistry procedure) provided on 1/17/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the DecisionDx-Melanoma Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx test has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Overall, there is not enough published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx-Melanoma Assay provided on 1/17/17 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 Upheld

Summary Reviewer 2

A 51-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma Assay (CPT code 84999 - unlisted chemistry procedure) provided on 1/17/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma Assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of this patients melanoma. Moreover, the DecisionDx-Melanoma Assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma Assay provided on 1/17/17 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 Upheld

Summary Reviewer 3

A 51-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma Assay (CPT code 84999 - unlisted chemistry procedure) provided on 1/17/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. DecisionDx-Melanoma Assay assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class 1 consistent with a low risk of metastasis or Class 2 suggestive of a high risk of metastasis. One peer-reviewed publication indicated that there was a statistically significant association of a Class 1 signature by DecisionDx-Melanoma Assay for primary dermal melanoma (PDM), whereas cutaneous metastatic melanoma (CMM) were more frequently Class 2 (Sidiropoulos, et al). The authors concluded that the melanoma prognostic assay may be a useful tool for distinguishing PDM from CMM. Therefore, DecisionDx-Melanoma Assay signature may be an independent predictor of metastasis risk. However, there is a lack of peer-reviewed published studies confirming this hypothesis. All told, the DecisionDx-Melanoma Assay performed on 1/17/17 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


A 58-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/10/15.  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 current medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis allows providers to differentiate dense glandular elements from underlying architectural distortion which in turn has been associated with a decrease in callbacks and increase in detection of small cancers.  The medical literature supports the breast tomosynthesis in this patients case.  Thus, the addition of tomosynthesis to the usual two-dimensional imaging protocol was likely of more benefit for the patient than had the examination been done with the two-dimensional technique alone.  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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 58-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/10/15.  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 medical literature supports breast tomosynthesis in this patients case.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Thus, the breast tomosynthesis performed on 7/10/15 was likely to have been more effective than other modalities 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 58-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/10/15.  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 breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  However, in this patients case, there were no problems to be resolved.  The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications.  In addition, there had been no change when compared to yearly mammograms dating back eight years.  Thus, breast tomosynthesis performed on 7/10/15 was not likely to have been of greater benefit 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 1

A 58-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 1/03/17 and transfer of the laboratory specimen. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the DecisionDx-Melanoma testing is a 31-gene expression profile used to determine the risk of recurrence of melanomas. Per the National Comprehensive Cancer Network guidelines, routine (baseline) prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. At this time, the medical evidence has not established that the results of such genetic profiles has an independent prognostic value. The standard of care for the patient would have been wide excision and consideration of sentinel lymph node sampling, and additional follow-up could be determined by those results.  All told, DecisionDx-Melanoma testing performed on 1/03/17 and transfer of the laboratory specimen 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 2

A 58-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 1/03/17 and transfer of the laboratory specimen. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines do not support the services at issue in this clinical setting, as routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical trial. The medical evidence does not support the services at issue in this clinical setting. In sum, DecisionDx-Melanoma testing performed on 1/03/17 and transfer of the laboratory specimen was not likely to have been of greater benefit than other available modalities for 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

A 58-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 1/03/17 and transfer of the laboratory specimen. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. 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 to 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 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, the superior effectiveness of DecisionDx-Melanoma testing performed on 1/03/17 and transfer of the laboratory specimen has not been established in this patients case. 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 Upheld

Summary Reviewer 


A 57-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI). The Health Insurer has denied this request indicating that the requested service is not medically necessary for evaluation of the enrollees left-sided back pain.   The physician reviewer found that based on the findings on the 1/24/17, a repeat MRI is not medically necessary for further evaluation of this patients medical condition. If the first MRI study was inadequate due to motion, a repeat limited examination should have been performed at the original facility. However, the records provided for review do not demonstrate that the initial MRI study was inadequate as there is no description of artifact or inadequate imaging by the interpreting provider. Thus, the requested MRI is not supported as medically necessary. Based on the foregoing, the requested service is not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a 15-year-old female enrollee has requested authorization and coverage for a power wheelchair. 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 The request for a power wheelchair is medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient presents with Friedreichs ataxia which is an inherited autosomal recessive disorder characterized by central nervous system damage to the spinal cord, cerebellum, and medulla, manifest as slowly progressive ataxia. Ataxia involves the lower extremities more than the upper extremities. Patients also exhibit characteristic explosive dysarthric speech and nystagmus. There may be weakness of the distal musculature, progressive kyphoscoliosis, loss of vibration and position sense, and progressive hypertrophic cardiomyopathy. Cognitive function is generally intact. Patients with severe disabilities requires specialized equipment in order to participate in activities of daily living while minimizing risk of complications and optimizing independence. In this case, the patients disabilities necessitate specialized equipment to allow for functional mobility, social and therapeutic interactions, and preparation for transition to adulthood. She is no longer able to maneuver her manual wheelchair despite modifications, limiting her mobility. A power wheelchair is medically necessary to allow her to move throughout her environment, functioning as independently as her physical limitations will allow. For the reasons stated, the requested power wheelchair is indicated for this patient. Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 56-year-old female enrollee has requested authorization and coverage for Xadago. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting. Bette and colleagues noted in large clinical trials of patients with early Parkinsons disease on a single dopamine agonist, Xadago administered orally at a dose of 100 mg daily improved overall motor function as measured by Unified Parkinsons Disease Rating Scale (UPDRS) part III total score. Safinamide is generally well-tolerated and safe, with few to no treatment-related adverse events. Safinamide does not cause new or worsening dyskinesia and may be able to reduce this symptom in patients reporting it at baseline. In this patients case, the records document early onset Parkinsons disease. Long duration use of carbidopa/levodopa therapy can lead to the development of motor side effects. The patient is likely to benefit from the requested medication. Therefore, Xadago is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 50-year-old male enrollee has requested reimbursement for Guardant360 testing performed on 8/31/18. 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 sufficient support for the services at issue in this clinical setting. Adenocarcinoma of the lung should be evaluated for specific molecular abnormalities, such as EGFR, ALK, ROS-1 and PDL-1. These have clear therapeutic implications, and such testing is done preferentially on tissue sampling. If this is not possible or not safe, plasma cell-free DNA testing (Guardant assay) is a reasonable alternative. The services at issue were likely to have been of clinical benefit in this patients case. Therefore, Guardant360 testing performed on 8/31/18 was likely to have been more effective than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 50-year-old male enrollee has requested reimbursement for Guardant360 testing performed on 8/31/18. 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 molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care for patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Integration of plasma next-generation sequencing testing into the routine management of stage IV non-small cell lung cancer demonstrates a marked increase of the detection of therapeutically targetable mutations and improved delivery of molecularly guided therapy. In sum, Guardant360 testing performed on 8/31/18 was likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 50-year-old male enrollee has requested reimbursement for Guardant360 testing performed on 8/31/18. 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 sufficient support for a portion of the services at issue. The records document non-small cell lung cancer. The patients provider recommended Guardant360 testing, and this was performed on 8/31/18. The medical evidence supports EGFR, ALK, ROS1, BRAF, MET, RET and ERBB2, as these are actionable mutations. There is a lack of support for the other mutations which were tested. Thus, a portion of the services at issue was likely to have been superior over other methods of evaluating this patient.