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

Summary Reviewer 


The parent of a 12-year-old male enrollee has requested authorization and coverage for growth hormone therapy. 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 submitted documentation fails to establish the medical necessity of the requested services. According to the documentation submitted for review, the patients height is not more than 2 standard deviations below normal for age and gender, his growth velocity is within normal limits, IGF-1 is normal, and peak GH response to provocative testing is normal. Thus, the patient does not have auxological or biochemical criteria for GH deficiency. The delayed bone age and small anterior pituitary gland without evidence of midline defects or other pituitary deficiencies is most consistent with a diagnosis of constitutional delay rather than GH deficiency. The adult predicted height based on a bone age of 10 years and height measurement of 133.4 cm in 9/8/14 is 64.7 inches, not short enough to warrant a trial of GH therapy for idiopathic short stature based on U.S. Food and Drug Administration criteria. Based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.Therefore, the requested services are 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 56-year-old male enrollee has requested reimbursement for genetic testing performed on 2/28/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that as a standard of care, metastatic colon cancers should be tested for KRAS, NRAS, BRAF, HER2, and microsatellite instability or mismatch repair (MMR) testing. Per the National Comprehensive Cancer Network (NCCN) guidelines, these can be done individually or as part of next-generation sequencing. Next-generation sequencing panels have the ability to pick up rare and actionable mutations and fusions. Universal genetic testing is recommended on all colon cancer tumors, and next-generation sequencing allows for initial screening with microsatellite instability testing. Next-generation sequencing offers the advantage of identifying markers known to have targeted therapy as well as potential clinical trials. FoundationOne is one available test that offers this. The medical evidence supports the services at issue in this clinical setting. Therefore, genetic testing performed on 2/28/18 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 78-year-old male enrollee has requested reimbursement for physical therapy visits provided from 9/2/16 through 12/23/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees status post open reduction with internal fixation (ORIF) of the left femur fracture. The physician reviewer found the physical therapy visits provided from 9/2/16 through 12/23/16 were not medically necessary for treatment of the patients medical condition. As of 9/2/16, the patient was more than nine months status post injury and more than six months had elapsed after the reported hardware failure. There was no new injury or change in orthopedic status or management plan. He had chronic residual lower extremity impairment related to his injury and surgery. He was ambulating with less reliance on a cane. The patient had a unilateral lower extremity impairment and would be expected to be able to independently perform a home exercise program without requiring specialized equipment or ongoing skilled therapy oversight. A daily home exercise program would likely have best met this patients needs. Thus, 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.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 35-year-old male with a history of ulcerative colitis. Anser ADA testing on 6/10/19 showed a Humira level of 6.7 ug/mL and lack of anti-Humira antibodies. The physician reviewer found that this patient was taking Humira, an anti-tumor necrosis factor (TNF) medication, for the treatment of ulcerative colitis. In this case, Humira levels and anti-Humira antibody levels were checked after the patient had uncontrolled symptoms of ulcerative colitis. According to the American Gastroenterological Association (AGA) Guideline on Therapeutic Drug Monitoring in Inflammatory Bowel Disease, In adults with active inflammatory bowel disease treated with anti-tumor necrosis factor agents, the AGA suggests reactive therapeutic drug monitoring to guide treatment changes. The current medical literature supports drug level monitoring based on studies showing that anti-TNF drug levels predict response to therapy. In this case, the patient was stabilized on Humira, and then had a loss of response, which requested prednisone therapy. Testing for Humira drug level and for anti-Humira antibodies is supported by guidelines in that situation. Therefore, Anser ADA diagnostic testing performed on 6/10/19 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 64-year-old female enrollee has requested reimbursement for injection, anesthetic agent, greater occipital nerve, provided on 6/05/19 and 6/12/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that there are no medications or procedures that have U.S. Food and Drug Administration (FDA) approval for the treatment of occipital headache. Likewise, there are no medications approved for treatment of Chiari malformation related headache. Positional headache as described can represent cervicogenic headache. Standard treatment for this includes diagnostic and therapeutic anesthetic blocks. This patient has been treated with medications that can help neuropathic pain, without benefit. Per the literature, conservative therapeutic approaches are considered first-line. Anesthetic nerve blocks may have a dual role in both supporting diagnosis and providing pain relief. Newer minimally invasive procedures, such as pulsed radiofrequency and occipital nerve stimulation, represent an exciting therapeutic avenue for severe/refractory cases. Surgical interventions should be reserved for select patient populations who have failed all other conservative and minimally invasive options, to be weighed against potential risk. There is considerable evidence that anesthetic blocks and steroids can be beneficial for neuralgia, migraine, and cervicogenic headache. There is sufficient support for the services at issue in this clinical setting. Therefore, injection, anesthetic agent, greater occipital nerve provided on 6/05/19 and 6/12/19 were likely to have been more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 64-year-old female enrollee has requested reimbursement for injection, anesthetic agent, greater occipital nerve, provided on 6/05/19 and 6/12/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that in this case, the patients headache diagnosis is unclear and does not appear to meet specific guidelines based on the International Classification of Headache Disorders. The records report bilateral tenderness of the occipital nerves. However, there is no mention of the quality and intensity of pain (i.e., paroxysmal, sharp, shooting pain) suggestive of occipital neuralgia. In addition, there is no mention of other pain management methods recommended or used prior to the occipital nerve blocks. In sum, injection, anesthetic agent, greater occipital nerve provided on 6/05/19 and 6/12/19 were not likely to have been more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 64-year-old female enrollee has requested reimbursement for injection, anesthetic agent, greater occipital nerve, provided on 6/05/19 and 6/12/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue. The patient has been diagnosed with seizure disorder and Chiari malformation. The records document occipital headaches when supine. The use of occipital nerve blocks is typically indicated for greater occipital neuralgia and currently does not have any indicated for Chiari malformation. The sub-occipital headaches are mostly likely secondary to the Chiari malformation. The records do not support the diagnosis of greater occipital neuralgia. Thus, injection, anesthetic agent, greater occipital nerve provided on 6/05/19 and 6/12/19 were not likely to have been more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 51-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient has a medial talar dome osteochondral lesion with a large underlying bony cyst, and she has failed conservative management. Most studies looking at autologous chondrocyte implantation have been performed in the knee. Wasiak and colleagues concluded that while the use of autologous cartilage implantation and other chondral resurfacing techniques has become increasingly widespread, there is a lack of evidence of significant outcome differences between autologous cartilage implantation and other interventions. Currently, this procedure is not approved by the U.S. Food and Drug Administration (FDA) for use outside of the knee. At this time, the FDA has not approved the use of this technology in the ankle. Therefore, autologous chondrocyte implantation is not likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 51-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that current evidence-based medical literature supports the use of autologous chondrocyte implantation as a first-line treatment option for large articular cartilage defects. The literature supports treatment with bone marrow stimulation for lesions of smaller sizes, whereas treatment with autologous osteochondral transplantation may be utilized for larger or cystic lesions. The literature indicates that autologous chondrocyte implantation of the talus yields improvement in all parameters tested, with enduring long-term results in patients who have failed previous surgery for osteochondral lesions of the talus. This patient presents with a history of chronic severe right ankle pain and swelling. Significant functional limitations are noted that interfere with activities of daily living. There is imaging evidence of a very large cystic osteochondral lesion of the right talus. She has failed long-term conservative management as well as operative intervention. She is not a candidate for microfracture surgery due to the size of the lesion. Current evidence-based medical literature supports the use of autologous chondrocyte implantation in this clinical setting as a salvage procedure. In sum, autologous chondrocyte implantation is likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 51-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the records document a large osteochondral defect of the talus. Osteochondral lesions of the talus are difficult to treat because of the absence of healing reaction in damaged articular cartilage. Matrix-induced autologous chondrocyte implantation has been shown to be an effective method for treating cartilage lesions that fail to heal with the usual procedures, such as debridement and microfracture. The study by Kreulen and colleagues assessed the seven-year clinical follow-up data of matrix induced autologous chondrocyte implantation and demonstrated successful long-term healing. Ng and colleagues noted that autologous chondrocyte implantation and matrix-associated autologous chondrocyte implantation have shown promising results in osteochondral defects of the talus. This patients treatment options are limited. Thus, autologous chondrocyte implantation is likely to be more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


I am board certified in psychiatry and I am actively practicing. I am an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. In addition, I hold a current certification by a recognized American medical specialty board in the area or areas appropriate to the treatment under review. I have no history of disciplinary action or sanctions against my license. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  During the dates of service in dispute, both her mood and behavioral problems had improved. Per the records, she was medically stable, following directions, taking medication, and did not have aggressive, suicidal, or disruptive behaviors.  She did not exhibit active suicidal ideations. She had a greatly reduced incidence of purging, although she did continue to have some restricting and purging behaviors. The intensity of her symptoms could have reasonably been treated at a less invasive level of care.  All told, mental health intensive outpatient services from 11/03/15 through 12/24/15 were not medically indicated for the treatment of this patient.  Therefore, 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 Upheld

Summary Reviewer 1

A 59-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/10/18. 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 DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either class 1 or 2, with class 2 melanomas having a significantly higher rate of recurrence than class 1. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma testing classification in patients undergoing sentinel node sampling. This patient had recurrent melanoma both in skin and lymph nodes, which placed her in a high risk group for further recurrence, and she was already appropriately placed on adjuvant immunotherapy. In this patients case, the records do not demonstrate that DecisionDx-Melanoma testing was likely to have impacted her care or added to the prognostic information already known from her pathology results. Therefore, DecisionDx-Melanoma testing performed on 5/10/18 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 59-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/10/18. 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 had an early stage melanoma followed by a node positive recurrence. DecisionDx-Melanoma testing was performed on the recurrent tumor. Per the National Comprehensive Cancer Network guidelines, 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. The role of DecisionDx-Melanoma testing for recurrent node positive disease has not been established. In sum, DecisionDx-Melanoma testing performed on 5/10/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 59-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/10/18. 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 5/10/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 45-year-old male enrollee has requested reimbursement for gene analysis performed on 8/14/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that per the National Comprehensive Cancer Network (NCCN) guidelines, Extraocular recurrence or metastasis of ocular/uveal melanoma should be confirmed histologically whenever possible or if clinically indicated. The NCCN guidelines recommend that providers, Obtain tissue for genetic analysis (screening for mutations that may be potential targets for treatment or determine eligibility for a clinical trial) from either biopsy of the metastasis (preferred) or archival material if the patient is being considered for targeted therapy. Per NCCN guidelines, providers should consider broader genomic profiling if the test results might guide future decisions or eligibility for participation in a clinical trial. For patients with metastatic uveal melanoma, enrollment in a clinical trial is often recommended. The literature is not directive regarding the specific systemic agent(s) offering superior outcomes, but does provide evidence that uveal melanoma is sensitive to some of the same systemic therapies used to treat cutaneous melanoma. The medical evidence supports the services at issue in this clinical setting. Therefore, gene analysis performed on 8/14/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 58-year-old female enrollee has requested reimbursement for CPT code 95810 performed on 1/05/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. In this case, the patient presented with complaints of snoring. She had previously undergone a home sleep test in November 2017 which was non-diagnostic for obstructive sleep apnea. It has long been the standard of care for patients suspected of having obstructive sleep apnea to be referred for attended polysomnography in the setting of a negative home sleep test. The subsequent polysomnography revealed a diagnosis of obstructive sleep apnea, with the patient being found to have a RDI of 8.7. An RDI of 5.0 or greater is positive for obstructive sleep apnea based on current diagnostic standards. A home sleep test cannot detect respiratory effort-related arousal (used in calculating RDI) and may otherwise underestimate the degree of sleep related breathing disorder. In this case, performance of polysomnography would have been appropriate to rule in/out a diagnosis of obstructive sleep apnea in this setting of a negative home sleep testing. Therefore, CPT code 95810 performed on 1/05/18 was medically necessary for the evaluation of this patient. Therefore, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The parent of an 11-year-old female enrollee has requested authorization and coverage for gene testing.  The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the current medical evidence supports the requested services in this clinical setting.  Depending on which type of genetic mutation she has, this patients management may vary greatly and have an impact on her bone health and renal failure.  While neither syndrome can be reversed, the effects can be mitigated and modulated with appropriate therapy.  It is not possible to determine what type of syndrome to treat without genetic testing.  Whole exome sequencing is sensitive and specific and identifies changes in the DNA that are causative for the medical conditions, in contrast to current sequencing tests that analyze one gene or small groups of related genes.  If a mutation is identified, targeted medical care may be recommended and other testing can be avoided.  Whole exome sequencing would allow for genotype-phenotype correlation and allow therapy to be tailored accordingly.  All told, the requested gene testing is likely to be of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.