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

Summary Reviewer 1


The parent of a four-year-old female enrollee has requested reimbursement for chromosomal microarray (CMA) genetic testing performed on 9/16/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation the enrollees developmental delays. The physician reviewer found that chromosomal microarray genetic testing has become standard of care to evaluate children with developmental disabilities. Henderson and colleagues retrospectively reviewed the medical records of patients who had abnormal chromosomal microarray findings over a three-year period and quantified the management recommendations made in response to these results. The authors concluded that their results empirically demonstrate the clinical utility of chromosomal microarray by providing evidence that management was directly affected for the majority of patients in our cohort with abnormal chromosomal microarray findings. Similarly, Riggs and colleagues reported that 7% of microarray results impact clinical management, a rate which is similar to other genetic tests. Given the support in the peer-reviewed literature, the chromosomal microarray genetic testing performed on 9/16/15 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


The parent of a four-year-old female enrollee has requested reimbursement for chromosomal microarray (CMA) genetic testing performed on 9/16/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation the enrollees developmental delays. The physician reviewer found that the medical literature supports chromosomal microarray as the first-line for the evaluation of suspected genetic abnormalities. Coulter and colleagues showed that CMA influences medical management in a majority of the patients where an abnormality was found. Moreover, CMA is critical when clinical features suggestive of Williams syndrome are found (Sharma, et al). All told, CMA is the standard of care for evaluation of children with developmental delay. In this case, the patients positive CMA supports the chromosomal microarray genetic testing performed on 9/16/15 was likely to be more beneficial for evaluation of the patients developmental delay 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


The parent of a four-year-old female enrollee has requested reimbursement for chromosomal microarray (CMA) genetic testing performed on 9/16/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation the enrollees developmental delays. The physician reviewer found that CMA is recommended by the American College of Medical Genetics (ACMG) as a first-tier test for patients with developmental delay, intellectual disability, and/or multiple congenital anomalies (Manning, et al). Increasing numbers of patients have been found to have underlying copy number variations. As such, copy number variations on CMA may inform about possible other complications and medical risks, some of which can be screened for and treated. WS is caused by microdeletion of chromosome 7q11.23. Features of WS include cardiovascular disease, most commonly peripheral pulmonary stenosis or supravalvular aortic stenosis, distinctive facies, joint laxity, intellectual disability with specific cognitive profile and unique personality characteristics, slow growth abnormalities, and calcium abnormalities including hypercalcemia and hypercalciuria. This is an important diagnosis to make as cardiac, renal, and endocrine evaluation and ongoing care are necessary. Accordingly, the CMA genetic testing performed on 9/16/15 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 61-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/31/18. 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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami and colleagues reported on 217 cases, with a good correlation between the DecisionDx-Melanoma testing and prognosis in patients who have had sentinel node biopsy. Berger and colleagues reported on 156 cases, but there was not sufficient follow-up to determine the real value of the assay. It is not clear how the five-year DecisionDx-Melanoma testing data compares to the ten-year Balch data. Most importantly, it is not known if the DecisionDx-Melanoma testing result can be used to make clinical decisions. Therefore, DecisionDx-Melanoma testing performed on 10/31/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 61-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/31/18. 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 this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, 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. In sum, DecisionDx-Melanoma testing performed on 10/31/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 61-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/31/18. 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 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, 0.76-1.0 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 also 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, DecisionDx-Melanoma testing performed on 10/31/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 60-year-old female enrollee has requested authorization and coverage for Euflexxa injections. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. Hyaluronic acid injections in the knee are recommended as a possible option for patients with significantly symptomatic osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. If there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to perform another series. The peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat injections of viscosupplementation have been found to be safe and effective and allow for delay of total knee replacement. In this case, the patient has been diagnosed with osteoarthritis of the left knee. She presents with worsening left knee pain and functional mobility impairments. Clinical examination findings are consistent with radiographic evidence of tricompartmental osteoarthritis. She underwent a series of Euflexxa injections in May 2018 and June 2018, with significant pain reduction and improvement in her mobility that lasted six months. She has failed to achieve adequate relief with prior corticosteroid injection, nonsteroidal anti-inflammatory drugs, activity modification, physical therapy, and home exercise program. Therefore, the requested Euflexxa injections are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 47-year-old male who presented to the emergency department with abdominal/flank pain after a surfing accident. The patient has requested reimbursement for inpatient hospital stay provided on 10/06/20. The Health Insurer 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 at the time of admission, the patient was hemodynamically stable and afebrile with normal oxygen saturations on room air. His kidney function and hemoglobin levels were normal. The hematuria had cleared. The patient had not failed treatment as an outpatient. He did not require any urgent procedures. The inpatient admission was not medically necessary for this patient. 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. Therefore, inpatient hospital stay provided on 10/06/20 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1
A 61-year-old male enrollee has requested reimbursement for the Life Vest provided on 5/23/14. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees congestive heart failure and atrial fibrillation.  The physician reviewer found that based on the records provided, the patient presented with newly recognized severe left ventricular dysfunction in the setting of rapid atrial fibrillation and liver enzyme elevation. In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy. Moreover, there was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until at least 90 days have elapsed when continued left ventricular dysfunction is documented to persist in spite of appropriate treatment (Russo, et al). A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. Studies assessing the efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction of 35% or less before ventricular function has had a chance to recover have not demonstrated improved outcome (Hohnloser, et al). Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups (Chung, et al). Given these findings, the Life Vest provided to this patient on 5/23/14 was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the device at issue was 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 61-year-old male enrollee has requested reimbursement for the Life Vest provided on 5/23/14. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees congestive heart failure and atrial fibrillation.  The physician reviewer found that the Life Vest was not likely to be more beneficial for treatment of this patients condition compared to standard available therapies. The patient has newly diagnosed dilated non-ischemic cardiomyopathy. The Life Vest wearable defibrillator is generally accepted for patients who meet criteria for implantable cardioverter defibrillator (ICD) placement but have a temporary contraindication to device placement, such as infection. There is a lack of randomized, controlled trials supporting use of the wearable defibrillator for patients with a new diagnosis of dilated cardiomyopathy as opposed to optimal medical therapy alone. Based on the registry data by Chung and colleagues, there does not appear to be a significant benefit of the wearable defibrillator for this patients diagnosis. In the registry, there was a very low incidence of appropriate therapies for ventricular arrhythmias for this group of patients. It is recommended that the patient have a trial of optimal medical therapy. Consistent with these findings, the Life Vest provided on 5/23/14 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, I have determined the device at issue was 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 61-year-old male enrollee has requested reimbursement for the Life Vest provided on 5/23/14. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees congestive heart failure and atrial fibrillation.  The physician reviewer found that the review of currently available peer-reviewed literature does support the safety and efficacy of wearable cardioverter defibrillators (WCD) in this clinical setting. Chung and colleagues demonstrated low sudden cardiac death in patients at increased risk with WCD comparable to implantable cardioverter defibrillator (ICD) patients. However, Adler and colleagues indicated that when a wearable defibrillator is considered, there are no randomized, controlled studies showing that it provides survival benefit compared to standard alternatives. WCD is currently indicated for patients who have met medical necessity criteria for ICD deployment and are awaiting cardiac transplantation and have met criteria for cardiac transplantation, have had a previously implanted ICD explanted due to an infection and are awaiting ICD re-implantation, or have an infectious process or other temporary condition that would preclude initial implantation of an ICD. In this case, the WCD was deployed five days after the initial diagnosis was made and the patient did experience a return to normal LV function. All told, the Life Vest provided on 5/23/14 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, I have determined the device at issue was 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 47-year-old male enrollee has requested authorization and coverage for vestibular stenosis repair. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee, who has a history of nasal congestion and obstruction. The physician reviewer found that the patient had obstruction of nasal breathing. He underwent previous nasal surgery to restore nasal breathing which included valve repair. Based on the records, it was unclear if the previous surgery was on the internal or external nasal valve. The internal nasal valve is the narrowest area of the nose where turbulence of the inspiratory and expiratory current takes place. Internal valve collapse can lead to nasal obstruction. It is characterized by the collapse during inspiration of the upper lateral cartilages; a narrowing of the angle between the dorsal septum and upper laterals can also contribute, but to a lesser extent. Functional rhinoplasty procedures for internal nasal valve have evolved over the past decade. Placement of precise cartilage grafts have been demonstrated to provide support which improves nasal breathing. The external nasal valve is formed by the columella, the nasal floor, and the nasal rim (or caudal border of the lower lateral cartilage). Cartilage grafting can also support the external valve. Absorbable implants for lateral cartilage support in patients with nasal valve collapse have been developed. There are limited studies supporting the use of these implants. At this time, the requested vestibular stenosis repair 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 47-year-old male enrollee has requested authorization and coverage for vestibular stenosis repair. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee, who has a history of nasal congestion and obstruction. The physician reviewer found that there is sufficient support for the requested services in this case. This patient has lateral nasal wall collapse from lower lateral cartilage weakness. The images appear to show significant collapse. The Latera implant is a U.S. Food and Drug Administration (FDA) approved device which has been used successfully for lateral nasal wall collapse. In sum, vestibular stenosis repair is likely to be more effective 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.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 47-year-old male enrollee has requested authorization and coverage for vestibular stenosis repair. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee, who has a history of nasal congestion and obstruction. The physician reviewer found that the Latera implant is an absorbable material specifically designed to support the lateral nasal wall collapse in selected patients.  Currently, there is a lack of long-term objective data supporting the clinical advantage of the device, although there are some articles and anecdotal evidence that the device is useful. Stolovitsky and colleagues stated evidence for longer-term improvement in a prior cohort of patients examined at 12 and 24 months postoperatively provides hope that these results may be maintained for two years or more. Limitations of the study include a single arm study design with short-term follow-up. A randomized placebo control study design should be considered in the future. The current medical evidence has not demonstrated the superior efficacy of the requested services. Thus, vestibular stenosis repair is not likely to be more effective than 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.