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

Summary Reviewer 

The patient is a 31-year-old female who was transported from Sharp Memorial Hospital to Sharp Mesa Vista Hospital on 4/28/19. She had arrived at Sharp Memorial Hospital for attempted overdose. The physician reviewer found that this patient presented with suicidal ideation and was diagnosed with psychosis. The reason for transport is listed as psychiatric monitoring. Transportation of mental health patients between facilities by emergency medical services personnel poses a unique risk to both patients and their providers. Standard of care is to transport all such patients by basic ambulance. Special handling with the use of restraints could be required during transport to prevent self-injury by the patient as well as injury to transport staff. Emergency medical technicians (EMTs) possess the requisite training to apply restraints. Therefore, EMT attendance is required for such transports. There is sufficient support for the services at issue in this clinical setting. Therefore, non-emergent ambulance services provided on 4/28/19 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The physician reviewer found to the documentation submitted for review, the patient has evidence of a functional impairment related to her abnormal upper eyelid positions, related to significant eyelid ptosis. This is supported by physical examination, review of the photographs and functional improvement following her surgery. According to Zoumalan and Roostaeian Excess upper lid skin is the most common complaint a patient will describe with regard to the aging upper eyelid. Loss of elasticity results in increased skin folding over the lid crease. This is seen clinically as lash hooding where the skin overhangs and conceals the lid crease and, in severe cases, can even obstruct the visual field. Excess eyelid skin can obstruct the visual field and thus considered a functional problem. In this case, the patient presented with functional impairment related to her vision secondary to eyelid malposition in the form of ptosis. Her surgical procedure was consistent with correction and postoperatively she was noted to have improved vision. Therefore, the blepharoplasty performed on 6/3/16 was consistent with a medically necessary procedure.  Therefore, the procedure at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 46-year-old female enrollee has requested authorization and coverage for fentanyl citrate lozenge on a handle 200 mcg. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that in this case, the patient has chronic pain involving several areas, which is complicated by hereditary angioedema, a life-threatening condition that can be precipitated by triggers, including pain. The patient has multiple drug allergies to several opioid medications, which range in severity from hives to life-threatening anaphylaxis. Per the submitted documentation, she has been stable on her current regiment of fentanyl lozenges and patches without further episodes of angioedema or hospitalizations. Her provider has indicated that adequate pain control is an important component to managing her hereditary angioedema. The patient has not demonstrated any irregular behavior and has been functional with the high-dose opioid therapy. There is sufficient support for the requested medication in this clinical setting. Therefore, fentanyl citrate lozenge on a handle 200 mcg is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 66-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Expression Assay provided on 10/12/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. However, there is a lack of peer-reviewed published studies confirming the role of DecisionDx-Melanoma Gene Assay in this clinical setting. All told, the DecisionDx-Melanoma Gene Assay performed on 10/12/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was 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 66-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Expression Assay provided on 10/12/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma Gene Assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of this patients melanoma. Moreover, the DecisionDx-Melanoma Gene Assay was not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma Gene Expression Assay provided on 10/12/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 66-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Expression Assay provided on 10/12/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the DecisionDx-Melanoma Gene Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma Gene Assay has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Overall, there is a lack of published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx-Melanoma Gene Assay provided on 10/12/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was 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 41-year-old male has requested reimbursement for a wearable cardioverter defibrillator. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees non-ischemic cardiomyopathy. The physician reviewer found there is a lack of support for the device at issue in this clinical setting. The current medical literature does not support an improvement of health outcomes when a wearable cardioverter defibrillator is deployed in the treatment of a newly diagnosed non-ischemic cardiomyopathy prior to 90 days of guideline-directed medical therapy.  The device at issue was not likely to have been of greater benefit than any available standard therapy, which would include beta blockers, angiotensin receptor blockers and diuretics. The current standard of care requires 90 days of such therapy followed by a reassessment of ejection fraction. During the dates of service in dispute, this patient had not been medically treated for non-ischemic cardiomyopathy for 90 days.  In sum, the wearable cardioverter defibrillator was not likely to have been superior over other treatment options.  Based upon the information set forth above, 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 41-year-old male has requested reimbursement for a wearable cardioverter defibrillator. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees non-ischemic cardiomyopathy. The physician reviewer found this patient was diagnosed with non-ischemic cardiomyopathy and was started on medical therapy. Current guidelines recommend three months of aggressive congestive heart failure therapy to see if the ejection fraction improves enough to obviate the need for a permanent implantable cardioverter defibrillator to prevent sudden cardiac death.  There is some likelihood of recovery of left ventricular function in this instance over the initial three-month period with evidence-based medical therapy. Although implantable cardioverter defibrillators have been shown to be beneficial and indicated in both ischemic and non-ischemic cardiomyopathy, the current guidelines did not support implantable cardioverter defibrillator during the dates of service at issue. Per the guidelines, he requires a minimum of three months of evidence-based medical therapy of his left ventricular dysfunction, and then reassessment of ejection fraction prior to consideration for implantable cardioverter defibrillator. The patient is at risk for malignant arrhythmia and sudden death while his ejection fraction is low. A wearable cardioverter defibrillator can provide temporary protection from sudden death due to arrhythmia in this patient population during this interim period. Therefore, the wearable cardioverter defibrillator was likely to have been of greater benefit than other treatment options. Based upon the information set forth above, the device at issue was 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 41-year-old male has requested reimbursement for a wearable cardioverter defibrillator. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees non-ischemic cardiomyopathy. The physician reviewer found the medical records fail to demonstrate the superior efficacy of the device at issue in this clinical setting.  In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy, and there was no documented 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 a period of time greater than 90 days where continued left ventricular dysfunction (ejection fraction less than or equal to 35%) is documented to persist despite of appropriate treatment. A prophylactic defibrillator, either wearable or implantable, before this time has not been demonstrated to improve outcome. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explantation.  Per the current evidence, the wearable cardioverter defibrillator was not likely to have been of greater benefit than other treatment options. Based upon the information set forth above, 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 Overturned

Summary Reviewer 1

A 62-year-old female enrollee has requested reimbursement for the ThyGenX Thyroid Oncogene Panel testing provided on 11/18/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees thyroid nodule. The physician reviewer found that the patient has a 3.3 cm thyroid nodule, which had previously shown a biopsy consistent with FLUS. In FLUS the risk of malignancy if 5-15% (Cibas, et al). The most recent cytopathology was consistent with follicular neoplasm, which has a risk of malignancy of 15-30%. For FLUS, the Bethesda System recommends a repeat biopsy and for follicular neoplasm, a diagnostic lobectomy. 

The American Thyroid Associations guidelines state that for nodules with FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. In this case, the likelihood of the nodule being benign was high. With the negative result, the patient and provider can decide whether to continue surveillance versus diagnostic thyroidectomy. Given this support, the ThyGenX Thyroid Oncogene Panel testing provided on 11/18/15 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

A 62-year-old female enrollee has requested reimbursement for the ThyGenX Thyroid Oncogene Panel testing provided on 11/18/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees thyroid nodule. The physician reviewer found that while a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate (Alexander, et al). Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign (Miller, et al). The ThyGenX analyzes a panel of DNA mutations and RNA translocation fusion markers to assess the risk of malignancy with good negative and positive predictive value thereby obviating the need for unnecessary surgery. Currently, there is adequate data supporting the ThyGenX Thyroid Oncogene Panel testing provided on 11/18/15 as 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 3

A 62-year-old female enrollee has requested reimbursement for the ThyGenX Thyroid Oncogene Panel testing provided on 11/18/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees thyroid nodule. The physician reviewer found that thyGenX testing is generally considered standard protocol on all FNA samples taken on thyroid nodules. There is sufficient peer-reviewed medical literature demonstrating that this test can be easily performed and can help avoid needless surgeries. In this patients case, the initial biopsy results were indeterminate, and the ThyGenX testing results prevented the patient from having to undergo an unnecessary surgery. All told, the ThyGenX Thyroid Oncogene Panel testing provided on 11/18/15 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 Upheld

Summary Reviewer 


A 23-year-old female enrollee has requested reimbursement for the substance use residential rehabilitation services provided from 10/10/16 through 1/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees substance abuse. The physician reviewer found that the records provided for review document that this patient showed mild post-acute withdrawal symptoms and there was no evidence of suicidal or homicidal ideation. She attended to her activities of daily living and was cognitively intact. Emotionally she related that she wanted to grieve before participating in treatment. She did not demonstrate impulsivity. She did not show motivation or cooperation. Medically she was stable as her rheumatoid arthritis and medication therapy could have been managed on an ambulatory basis. She was at risk for relapse, however she was highly resistant. It was not until 10/15/16 that she began to show cooperation and motivation. Overall, the patient did not require 24-hour per day supervised medical and nursing level of care in residential treatment. She could have been treated in a less restrictive treatment setting in conjunction with community supports with 12 step programs, and a Subutex maintenance program on an outpatient basis. Thus, the substance use residential rehabilitation services provided from 10/10/16 through 1/6/17 was not medically necessary for treatment of this patients medical condition. Based on these findings, the services at issue were 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 57-year-old female enrollee has requested reimbursement for comprehensive cancer genomic panel provided on 5/9/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees rectal carcinoma. The physician reviewer found that patients with refractory or relapsed cancer that have exhausted standard treatments are usually considered for clinical trials. Recently, it has become important to identify mutations that may be amenable to targeted therapy. One study of 86 patients reported that progression free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen (Von Hoff, et al). The regimen selected by molecular profiling offered a 27% survival advantage. Given this support, the comprehensive cancer genomic panel provided on 5/9/17 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

A 57-year-old female enrollee has requested reimbursement for comprehensive cancer genomic panel provided on 5/9/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees rectal carcinoma. The physician reviewer found that FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individual patients tumor with the hopes of identifying markers than can help guide therapy decision making. Per the National Comprehensive Cancer Network (NCCN) guidelines, KRAS, NRAS, and BRAF mutations, and microsatellite instability (MSI) markers may provide some guide toward possible treatment options. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy (Benson, et al). Thus, the KRAS, NRAS, BRAF, MLH1, MSH2, MSH6 and PSM2 portions of the testing performed on 5/9/17 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the remainder of the testing 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, a portion of 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 partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 57-year-old female enrollee has requested reimbursement for comprehensive cancer genomic panel provided on 5/9/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees rectal carcinoma. The physician reviewer found that to demonstrate clinical utility of panel testing for somatic genomic alterations, such as FoundationOne, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with the standard of care. The available literature on clinical utility consists of a small number of uncontrolled studies, and nonrandomized controlled trials that use imperfect comparators. This evidence is insufficient to make conclusions on clinical utility. All told, the comprehensive cancer genomic panel provided on 5/9/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.