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

Summary Reviewer 1

A 57-year-old female enrollee has requested reimbursement for the gene test performed on 8/12/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the commercial gene expression profile test (DecisionDX-Melanoma) has been developed in patients with stage I and II cutaneous melanoma. However, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials according to published data available. Per the National Comprehensive Cancer Network (NCCN) guidelines, the gene expression profile test is still not recommended for routine (baseline) genetic testing of primary cutaneous melanomas.  At this time, the gene test performed on 8/12/15 was not likely to be of greater benefit than available standard therapy for the evaluation of 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 57-year-old female enrollee has requested reimbursement for the gene test performed on 8/12/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the services at issue were not likely to be more effective than other methods of evaluating this patient. The clinical utility of the gene expression assay for cutaneous melanoma has yet to be determined. Moreover, the National Comprehensive Cancer Network (NCCN) Guidelines have not recommended this test outside of a clinical study (trial). In this patients case, the gene test performed on 8/12/15 was not likely to be superior to available standard therapy for the evaluation of this patients malignant melanoma. 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 57-year-old female enrollee has requested reimbursement for the gene test performed on 8/12/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that there is a lack of medical studies to support the superior efficacy of this gene test in this patients case. The standard therapy for stage I malignant melanoma is surgical excision. The current body of medical research indicates that there is very little benefit from adjuvant therapy. The clinical trials have only looked at adjuvant therapy in lymph nodes positive for the disease. Regardless of the risk or recurrence determined by this test, the implications on therapeutic decisions cannot be validated by data and therefore, would not help direct therapy. Moreover, the gene test has not been shown to improve a patients health outcome over established alternatives. For these reasons, the gene test performed on 8/12/15 was not likely to have been more effective than available standard tests for the evaluation of 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 1


A 64-year-old female has requested reimbursement for FoundationOne testing performed on 1/13/16.  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 support for the services at issue in this clinical setting.  Molecular profiling of a patients cancer cells, as is done with FoundationOne testing, is an assay of genomic or molecular abnormalities. The goal would be to identify a target at which a specific treatment could then be offered.  At this time, there is a lack of convincing evidence that the assay adds to decision making ability in a way to significantly improve patient outcome.  There are a variety of non-randomized studies exploring the value of molecular profiling that have as yet not been convincing.  A recent randomized study by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular targets.  Therefore, FoundationOne testing performed on 1/13/16 was not likely to have been more efficacious 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 64-year-old female has requested reimbursement for FoundationOne testing performed on 1/13/16.  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 submitted documentation fails to demonstrate the superior efficacy of the services at issue.  Carcinosarcoma is an aggressive uterine cancer often treated similar to high-grade endometrial cancer.  Per the medical evidence, molecular genetics on individual tumors has not yet been shown to be fruitful in the majority of cases.  This testing is not recommended as a standard of care for the treatment of uterine cancers per the current guidelines.  In sum, FoundationOne testing performed on 1/13/16 was not likely to have been superior over 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 3


A 64-year-old female has requested reimbursement for FoundationOne testing performed on 1/13/16.  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 sufficient support for the services at issue in this patients case.  The study by Von Hoff and colleagues evaluated 86 patients, and the progression-free survival on the regimen selected by molecular profiling was compared to the progression-free survival on the last chemotherapy regimen.  The regimen selected by molecular profiling offered a 27% survival advantage.  This trial has very significant results for patients with stage IV tumors.  In this clinical setting, the results from molecular profiling may offer a rational selection of the next regimen.  Therefore, FoundationOne testing performed on 1/13/16 was likely to have been of greater benefit than other methods of 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 Upheld

Summary Reviewer 

The patient is a 60-year-old female with a history of hypertension, coronary artery disease with angina and anxiety who was admitted to the hospital at an inpatient level of care on 2/15/19 with a diagnosis of intractable left hip pain and left lower extremity pain. The patient has requested reimbursement for inpatient stay at Glendale Memorial Hospital from 2/15/19 through 2/20/19. The Health Plan has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that most people with acute or subacute musculoskeletal pain will improve over time regardless of treatment. Per Qaseem and colleagues, clinicians and patients should select non-pharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation over pharmacologic intervention. The authors noted, aIf pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants.a Patients with chronic pain are recommended to participate in rehabilitation, exercise and other non-pharmacologic modalities. Per the authors, if pharmacologic therapy is indicated, then treatment with nonsteroidal anti-inflammatory drugs are a first-line therapy, or tramadol or duloxetine as a second-line therapy for chronic pain. In this patientas case, the inpatient admission was not medically necessary. Inpatient care is necessary when the patientas signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. At the time of admission, she was hemodynamically stable without any physical findings or symptoms concerning for a neurologic emergency, such as cauda equina syndrome. She was able to void and ambulate with assistance from her husband. She required pharmacologic treatment of acute pain in the hip and low back, but her pain improved with treatment.  Her cardiac status remained stable, without any evidence of acute coronary syndrome.  She was discharged home with plans for outpatient physical therapy. Therefore, inpatient stay at Glendale Memorial Hospital from 2/15/19 through 2/20/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 




A 63-year-old male enrollee has requested reimbursement for physical therapy services provided from 1/5/15 through 10/27/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees multilevel stenosis. The physician reviewer found that although a multidisciplinary approach to spine pain including PT may be beneficial, the goal of therapy is to transition to an independent home exercise program without continued dependence on supervised therapy. The documentation does not indicate that prior extensive PT before 1/5/15 resulted in significant objective increase in overall function. The services at this point do not need to be only under the supervision of a therapist. The patient has had extensive prior PT and should be well versed in a home exercise program. The additional requested therapy is not accepted as specific and effective therapy for this patients condition. Further, the patients expected rehabilitation potential is not significant in relation to the extent and duration of PT services required. The specialized skill of a qualified therapist is not required to establish, design and/or deliver a maintenance program to maintain the patients current condition or to prevent or slow further deterioration. All told, the PT services provided from 1/5/15 through 10/27/15 were not medically necessary for treatment of this patients medical condition. 
Based on the foregoing discussion, the services at issue were 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 63-year-old female enrollee has requested reimbursement and prospective authorization and coverage for physical therapy provided from 8/17/15 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found according to the documentation submitted for review, the patient had post-operative disability after foot surgery and physical therapy was prescribed to improve function. The patient made improvement in physical therapy through 8/19/15. On that date further physical therapy was reasonable and medically necessary because the patient had continued deficits that are generally amenable to the care of a skilled physical therapist. Based on improvement up to 8/19/15, further improvement could be expected with skilled services. However, the patient did not show further improvement. As such, six additional physical therapy sessions after 8/19/15 were sufficient to show a plateau. After these six sessions, the patient could have been managed with a home exercise program. For the reasons provided, a portion of the services at issue were 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 64-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that upon review of available data, proton therapy may be equivalent to, but not more beneficial than standard available therapy with photon based intensity modulated radiation therapy (IMRT) for prostate cancer. Proton therapy provides a Bragg peak, resulting in decreased dose before and after the peak, which translates into a decrease in exposure of normal tissue in the low- to intermediate-dose range, but not in the high-dose range (Trofimov, et al). Dosimetric studies have shown a benefit in bladder and rectal exposure with this regard. However, these findings do not appear to result in decreased clinical side effect (Sheets, et al; Coen, et al; Yu, et al; Hoppe, et al). Cancer control rates are also reportedly similar between photons and protons (Coen, et al). Accordingly, the requested proton beam radiation therapy is 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 requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 64-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that the most National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer acknowledge ongoing studies but caution that there is no clear evidence supporting a benefit or decrement to proton therapy over [intensity modulated radiation therapy] IMRT for either treatment efficacy or long-term toxicity. To date, there is a paucity of compelling data to suggest that proton therapy is superior to or more beneficial than IMRT. The current standard of care for prostate cancer is to offer proton beam therapy only as a part of a clinical trial and not as a substitute for IMRT. Thus, the requested proton beam radiation therapy is not supported 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 requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 64-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that there are several clinical publications for safety and efficacy of proton beam radiation for prostate cancer. However, there is a lack of randomized trials demonstrating superior clinical outcome of proton beam for prostate cancer over commonly used intensity modulated radiation therapy (IMRT). Most providers have recommended additional study on the long-term safety and efficacy of protons compared with photons before adopting protons as a viable treatment option for prostate cancer. The National Comprehensive Cancer Network (NCCN) guideline state that proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or within prospective registries. Given these findings, the requested proton beam radiation therapy is 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 requested services are 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 

The parent of a 17-year-old female enrollee has requested reimbursement for inpatient residential mental health treatment provided from 1/16/15 through 6/01/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the patient was diagnosed with major depressive disorder, recurrent, moderate with anxious distress, bulimia nervosa, panic disorder, generalized anxiety disorder, and borderline personality disorder.  She has a history of multiple hospitalizations for suicidal ideation/attempts in the year prior to admission, which impaired her functioning across multiple settings.  Per the submitted documentation, she had one documented intensive outpatient program experience from 7/18/14 through 7/20/14, in between two inpatient admissions.  The patient and her family were committed to treatment, and she stated that she wanted to work on her suicidality, eating disorder, and self-harm behaviors.  At the time of admission on 1/16/15, a lower level of care was not appropriate to meet her needs, as she required more intensive monitoring.  In this patients case, inpatient residential mental health treatment was medically indicated from 1/16/15 through 1/28/15.  By 1/28/15, although still reporting depression, the patient rated her mood as 6/10.  The patients baseline behavior, prior to admission, is the expression of suicidal ideation and self-harm urges.  Much of her self-harm behaviors were scratching herself with her fingernails.  These behaviors continued throughout her stay and can be considered chronic in nature, which would not require treatment at residential level of care.  All told, inpatient residential mental health treatment provided from 1/16/15 through 1/28/15 was medically indicated for the treatment of this patient, 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 44-year-old female enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees sacroiliac joint pain. The physician reviewer found that this patient presents with chronic left sacroiliac joint pain following childbirth, and chronic low back and left leg pain and paresthesias. She has been diagnosed with left sacroiliac joint pain, sacroiliitis, and sacroiliac joint dysfunction. She has reportedly failed extensive conservative treatment options, including physical therapy, home exercise program, chiropractic care, bracing, and nonsteroidal anti-inflammatory drugs. On 4/05/18, left sacroiliac joint corticosteroid injection reduced pain from grade 6/10 to 4/10 (33%) for less than one week. There is no imaging study presented to evidence sacroiliac joint spondyloarthropathy, degenerative sacroiliitis, or sacroiliac joint disruption. Current evidence-based guidelines and literature support minimally invasive sacroiliac joint fusion for patients with sacroiliac joint dysfunction due to degenerative sacroiliitis or sacroiliac joint disruption. However, current evidence-based guidelines do not support sacroiliac joint fusion for mechanical low back pain, non-specific low back pain, sacroiliac joint disruption (in the absence of major pelvic fracture), degenerative sacroiliitis or sacroiliac joint osteoarthritis. In this case, there is no clear evidence of a condition for which sacroiliac joint fusion is supported. Additionally, diagnostic injection response does not meet the standards of at least 75% decrease in pain. Therefore, sacroiliac joint fusion is not likely to be superior over other treatment options. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 44-year-old female enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees sacroiliac joint pain. The physician reviewer found that the sacroiliac joint degeneration is a common cause of chronic low back pain which is underdiagnosed. Minimally invasive fusion procedures have demonstrated successful pain relief for these patients.  Recent medical literature has documented two-year follow-up of these procedures demonstrating meaningful clinical improvement and maintained pain relief as well as evidence of a solid fusion on imaging studies. In the absence of evidence of neural compression on the magnetic resonance imaging (MRI) scan and in the presence of clinical findings of sacroiliac pain which is relieved by injecting the sacroiliac joint, the requested procedure of sacroiliac fusion using the minimally invasive technique is likely to be beneficial in this case. As such, the requested sacroiliac joint fusion is likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.