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

Summary Reviewer 1


A 20-year-old male enrollee has requested reimbursement for the Anser IFX testing provided on 10/26/15. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease status post resection. The physician reviewer found that some evidence exists to suggest that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures. 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. However, the reasons for therapeutic failures remain unclear. Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there are few well controlled clinical trials to confirm that use of the Anser IFX testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al). All told, the Anser IFX testing provided on 10/26/15 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 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 20-year-old male enrollee has requested reimbursement for the Anser IFX testing provided on 10/26/15. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease status post resection. The physician reviewer found that in this case, Anser IFX was ordered to determine the patients infliximab level and whether antibodies to infliximab were present. However, the use of Anser IFX to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease. The presence of antibodies does not necessarily result in loss of response to infliximab, nor have clear infliximab levels been established (Steenholdt, et al). Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response (Vande Casteele, et al; Nanda, et al). A recent study concluded that prospective evaluation of the value of measuring serum concentrations of infliximab should be performed before these data can be included in patient management strategies (Adedokun, et al). One study, with some patients undergoing dose intensification following initial non-response, showed no difference in serum levels of infliximab between patients who responded to dose intensification versus those who did not (Pariente, et al). Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing (Vande Casteele, et al). Based on the current clinical literature, the Anser IFX testing provided on 10/26/15 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 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 20-year-old male enrollee has requested reimbursement for the Anser IFX testing provided on 10/26/15. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease status post resection. The physician reviewer found that the patient has had Crohns disease that necessitated bowel resection. The records indicate the patients ileitis has also been complicated by Clostridium difficile and abscess. The patients symptoms remained active and it was unclear whether it would be Crohns disease from undertreatment or antibody development versus other complicating factors. Hence, an Anser IFX test was sent to help determine such. In this case, there is concern as the disease is advanced and the patient had already failed several regimen and flared on all. The concern between total loss of response, low antibody level to the biologic, or a completely different diagnosis such as inflammatory bowel disease entails different and drastic measures varying from surgery, change or increase in dose of biologic, to symptomatic adjunct treatment in case of inflammatory bowel disease. Therapeutic levels and lack of antibodies may point the provider toward a different drug versus another etiology. It follows, that testing for antibodies identifies the subset of patients who will benefit from an increased dose, instead of doing such blindly and risking unnecessary potentially risky outcomes and adverse effects. Conversely, missing a sub-therapeutic Remicade level suggests progression of the disease, which could be avoided by dose adjustment as guided by the Anser IFX assay. Moreover, it has been shown that checking for such antibodies helps optimize clinical response by helping achieve a more optimal drug concentration. For these reasons, the Anser IFX testing provided on 10/26/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 64-year-old female enrollee has requested reimbursement for residential mental health services provided from 4/6/15 through 5/5/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the residential mental health services provided from 4/6/15 through 5/5/15 were medically necessary for treatment of the patients medical condition. Based on the additional documentation submitted for review, the patient demonstrated a complex illness burden that encompassed all elements of the biopsychosocial conceptualization which presented a challenging placement determination. In this case, the patient was isolative. She had not been employed in more than 20 years. She had no children. She had limited social support and was the primary care giver for her spouse who suffered from Parkinsons disease. Additionally, the patient had formidable, co-occurring mood and anxiety disorders. This is of particular relevance since it has been well-established in both clinical practice and the medical literature that anxiety-ridden mood disorders, even without the complication of pathological personality traits, are notoriously difficult to treat and in general have poor outcomes (Fava, et al). The patient remained symptomatic despite the delivery of multiple evidence-based interventions during the episode of illness. Based on the duration of symptoms, relevant clinical history, psychosocial factors and characterological influences, safe and effective care could not have been adequately provided in a less restrictive setting at the time. Thus, the residential mental health services provided from 4/6/15 through 5/5/15 was medically necessary for treatment of the patients behavioral health condition. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 55-year-old female enrollee has requested reimbursement for gene test (molecular profiling) performed on 2/18/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of lung cancer.The physician reviewer found there is some support for a portion of the services at issue in this clinical setting. Specifically, testing for the T790M mutation was beneficial. Genomic testing, using the Guardant360 test, interrogates more than 72 genes while all that is required. However, the National Comprehensive Cancer Network (NCCN) guidelines note that for patients with known EGFR mutation, testing for the T790M EGFR mutation is recommended. As such, in this patients case, there was a clinical benefit from testing for the T790M mutation and for the portions of the panel. Prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. There is a lack of published trials that demonstrate the clinical utility of this genomic testing. The available literature on its clinical utility consists of a small number of uncontrolled studies, and nonrandomized controlled trials that use imperfect comparators. This evidence is not sufficient to make conclusions on clinical utility. In addition, there is potential for harm if ineffective therapy is provided based on test results because there may be adverse effects of therapy in absence of a benefit. As a result, the use of expanded mutation panel testing for targeted treatment in cancer is considered investigational and should only be conducted in the setting of a clinical trial. All told, a portion of the gene test (molecular profiling) performed on 2/18/16 was likely to have been more effective than the available standard therapy for the evaluation of this patients medical condition. Based upon the information set forth above, a portion of the services 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 partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 55-year-old female enrollee has requested reimbursement for gene test (molecular profiling) performed on 2/18/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of lung cancer. The physician reviewer found the medical literature supports that adenocarcinoma of the lung should be tested for specific molecular abnormalities such as EGFR mutation. These have clear therapeutic implications (Temel, et al).  In this patients case, Tarceva was used because of her initial EGFR L858R mutation. Patients with that mutation, who are then treated with Tarceva, upon progression, can be found to have a further EGFR mutation (T790M). This appears to be true in about 50% of such patients, and it too has therapeutic significance.  One can test for such mutations either through tissue biopsy or in this case, through Guardant blood DNA assay. If a tissue biopsy is deemed inadvisable by the clinician, then the Guardant assay is considered reasonably accurate and easier on the patient. In this patients case, however, there were two tissue biopsies performed at about the same time as the Guardant assay. One of these biopsies showed no EGFR mutations; one showed the L858R mutation, but neither showed the T790M mutation. Thus, in this clinical setting there is no likely benefit to the additional Guardant assay. As such, the gene test (molecular profiling) performed on 2/18/16 was not likely to have been of greater benefit than the available standard methods of evaluating this patients medical condition. Based upon the information set forth above, the services at issue were not likely to have been 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 3

A 55-year-old female enrollee has requested reimbursement for gene test (molecular profiling) performed on 2/18/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of lung cancer. The physician reviewer found the National Comprehensive Cancer Network (NCCN) guidelines recommend that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. The NCCN guidelines strongly endorses 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 of patients with NSCLC. Multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially one by one. This is the most tissue efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time efficient process for screening patients and thus to facilitate prompt treatment or protocol inclusion. For the treatment of patients with advanced NSCLC, broad molecular profiling, such as with Guardant360 testing, is considered a standard of care. Therefore, the gene test (molecular profiling) performed on 2/18/16 was likely to have been of more beneficial than any available standard method for the evaluation of this patients medical condition. Based upon the information set forth above, the services at issue were likely to have been 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 53-year-old female enrollee has requested authorization and coverage for arthroscopic hip surgery. The Health Insurer has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees right hip pain.   The physician reviewer found that the records provided for review support the medical necessity for this patient to undergo the requested arthroscopic hip surgery. The patients records include anatomical studies which support a diagnosis of mixed cam-pincer type lesions at the right hip. Total hip arthroplasty would likely require revision and secondary procedures over the patients lifetime. In the article by Cheatham and colleagues, the authors noted that femoral acetabular impingement is a more commonly recognized intra-articular hip pathology and is often accompanied with a labral tear. Sansone and colleagues conducted a case series on 70 patients undergoing arthroscopic surgery for femoral acetabular impingement with preoperative radiological signs of mild-to-moderate osteoarthritis. The authors reported on findings at two-year follow-up using functional outcome measures. The authors reported that 82% of the 70 patients reported satisfaction with the outcome of the surgery. The diagnostic criteria included patient history, physical examination and radiological findings of either cam or pincer type changes or mixtures of both. The authors concluded that patients with mild-to-moderate osteoarthritis Tonnis grades 1 and 2 benefitted the most from arthroscopic treatment of femoral acetabular impingement. All told, the requested arthroscopic hip surgery is medically necessary for treatment of this patients mixed cam-pincer type femoral acetabular impingement syndrome with a tear of the acetabular labrum within the anterosupralateral quadrant of the right hip. Based on the foregoing discussion, the requested surgery 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 63-year-old female enrollee has requested authorization and coverage for the Flexitouch pneumatic compression pump system. The Health Insurer has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees lymphedema. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  This patient has pain associated with lymphedema.  Her provider has ordered a multimodality approach to treatment, including exercise, diet and decongestive lymphatic therapy (manual lymphoid drainage).  The patient has requested coverage for the Flexitouch pneumatic compression pump system versus the standard segmented pneumatic compression devices that the Health Insurer approves.  There is a lack of evidence indicating that a pneumatic compression device with calibrated gradient pressure (the Flexitouch pump) is more effective than standard segmented pneumatic compression devices.  All told, the requested Flexitouch pneumatic compression pump system is not medically indicated for the treatment of this patient.  Therefore, the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 43-year-old male enrollee has requested reimbursement for the left eye corneal collagen cross-linking provided on 7/21/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees progressive keratoconus. The physician reviewer found that Corneal cross-linking has been found to be a useful aid in treatment of patients with corneal ectasia following refractive surgery. Poli and colleagues concluded that corneal collagen cross-linking can stabilize progressive corneal ectasia, both primary and secondary, with no induced iatrogenic effects. All told, there is adequate data supporting the clinical utility of the left eye corneal collagen cross-linking provided on 7/21/16 as 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 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 43-year-old male enrollee has requested reimbursement for the left eye corneal collagen cross-linking provided on 7/21/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees progressive keratoconus. The physician reviewer found that treatment for this patients left eye with corneal collagen cross-linking provided on 7/21/16 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based on the patients vision loss and stage of keratoconus, the cross-linking was the most appropriate and effective treatment available. Overall, collagen cross-linking has been shown to be a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant. For these reasons, the left eye corneal collagen cross-linking provided on 7/21/16 was 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 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 43-year-old male enrollee has requested reimbursement for the left eye corneal collagen cross-linking provided on 7/21/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees progressive keratoconus. The physician reviewer found that Collagen cross-linking was recently approved in the U.S. as a treatment for progressive keratoconus (Jeng, et al; Sykakis, et al). In this case, while the records state that there was progression in the left eye, there is a lack of evidence consisting of topography, manifest refraction, and pachymetry provided for the review. Therefore, since none of the historic results of the objective tests that demonstrate the progression have been provided, the left eye corneal collagen cross-linking provided on 7/21/16 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 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


An 18-year-old male enrollee has requested reimbursement for substance use residential treatment center services provided from 2/26/17 through 3/5/17 and intensive outpatient program (IOP) services provided from 3/6/17 through 3/29/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the services at issue were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient was not in withdrawals. He was not a danger to himself or others. He was medically and psychiatrically stable. There were no emotional, behavioral, or symptoms that would warrant the levels of care in dispute. There was a lack of evidence demonstrating a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He was cooperative. He had sober support in his mother. He was motivated, however throughout both the residential and IOP dates he had frequent group dates showing that he showed up late, was distracted, or had little to no participation. The issues he was working on in both residential and IOP that included developing coping skills, accountability and family dynamics did not require the frequency of contact with providers in either of the settings in dispute. He did not require 24-hour monitoring in the residential setting. Treatment and recovery could have been provided at IOP level of care. Residential treatment level of care provided from 2/26/17 through 3/5/17 was not medically necessary. Moreover, the patient did not require IOP level of care. As of 3/6/17, he could have been treated at outpatient level of care with adjunctive 12 step attendance, and counseling if he so chose. Of note, the documentation provided for review did not show any changes in treatment plans, psychiatric admitting history, or any physician progress notes. As such, the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.