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

Summary Reviewer 

The patient is a 59-year-old female with alopecia universalis. She has tried and failed treatment with intralesional kenalog, topical calcineurin inhibitors, topical tofacitinib, and squaric acid, for which she had contact dermatitis. The physician reviewer found that according to the most recent published guidelines, the standard of care for the treatment of alopecia totalis/universalis, would include systemic steroids, methotrexate, cyclosporine, and contact sensitization with diphencyprone (DPCP) or squaric acid. The patient already had a side effect preventing further treatment with squaric acid. Few treatment methods have been evaluated by randomized controlled trials to determine the most efficacious modalities to treat alopecia areata (AA). Therefore, it is challenging for clinicians to guide patients regarding the best therapeutic options. Janus kinase inhibitors like Xeljanz have demonstrated beneficial results in treating extensive alopecia. There is evidence to support the use of Xeljanz in this clinical setting. Therefore, Xeljanz 5 mg tablet is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 48-year-old female has requested reimbursement for procedure codes 84999 (DecisionDx-Melanoma) and 99000 performed on 1/25/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the DecisionDx-Melanoma testing 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. 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 guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate benign from malignant neoplasms, or melanomas at low versus high risk for metastasis, routine (baseline) genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Therefore, procedure codes 84999 (DecisionDx-Melanoma) and 99000 performed on 1/25/17 were 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 48-year-old female has requested reimbursement for procedure codes 84999 (DecisionDx-Melanoma) and 99000 performed on 1/25/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. 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 more to these determinations. As per the Balch criteria, this patients melanoma would be considered a T1a, or stage 1A melanoma, with an expected ten-year survival in excess of 88%.  DecisionDx-Melanoma assay is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either Class 1 (with a five-year distant metastasis free rate of greater 90%) or Class 2 (65-80%). Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx classification, in patients undergoing sentinel node sampling. The records do not document that this patient had sentinel node biopsy. It is not clear how the five-year DecisionDx data compares to the ten-year Balch data, and, most importantly, whether it can be used to make clinical decisions. That would be particularly true in this patient given her excellent prognosis. In sum, procedure codes 84999 (DecisionDx-Melanoma) and 99000 performed on 1/25/17 were not likely to have been of greater benefit than other available modalities 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 48-year-old female has requested reimbursement for procedure codes 84999 (DecisionDx-Melanoma) and 99000 performed on 1/25/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the 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 to 1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggest 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 the DecisionDx-Melanoma test has not made it part of routine analysis after sentinel lymph node biopsy. There has 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, procedure codes 84999 (DecisionDx-Melanoma) and 99000 performed on 1/25/17 were not likely to have been more effective than other available 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 22-year-old female enrollee has requested reimbursement for mastopexy and reduction mammoplasty performed on 12/16/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees breast asymmetry. The physician reviewer found that as noted by the American Society of Plastic and Reconstructive Surgeons (ASPRS), breast deformities unrelated to cancer treatment occur in both men and women and may present either bilaterally or unilaterally. These deformities result from congenital anomalies, trauma, disease, or mal-development. Because breast deformities often result in abnormally asymmetrical breasts, surgery of the contralateral breast, as well as the affected breast, may be required to achieve asymmetry. Tuberous breast deformity is a well-defined type of congenital breast deformity and treatment for correction is considered reconstructive surgery. Breast reduction of the contralateral side and mastopexy of the affected side are recognized forms of surgical treatment for this condition. It is common in breast reconstruction to perform surgery on the contralateral side for the purpose of symmetry. The medical literature, as well as this patients clinical documentation and photographs, demonstrate the patient had a severe congenital deformity which was abnormal. Reconstructive surgery in this clinical setting was indicated to improve function and also to restore a more normal appearance. Consistent with these findings, the mastopexy and reduction mammoplasty performed on 12/16/14 were medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The parent of a 15-year-old male enrollee has requested authorization and coverage for Humatrope 24 mg cartridge, 2.2 mg injected. 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 the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient does not have a known hypothalamic-pituitary defect or a known deficiency of at least one pituitary hormone (other than growth hormone), which would allow the diagnosis of growth hormone deficiency without growth hormone (GH) stimulation testing. In addition, this patient does not have a medical condition for which growth hormone is strongly recommended, such as small for gestational age with failed catch-up growth. Based on this patients normal laboratory results and delayed bone age, the most likely diagnosis is idiopathic short stature. The 2008 consensus guidelines on idiopathic short stature describe a height Z score of -2 to -3 as the range to consider growth hormone therapy. Although this patients height Z score was -2.3 standard deviations below the mean at the time of growth hormone initiation, the predicted adult height of 67 to 68 inches is concordant with his mean parental height (68.75 inches). Additionally, the patient grew 2.6 cm from June 2018 to January 2019 before starting growth hormone therapy. Based on the records, the response to growth hormone therapy is likely secondary to a pubertal growth spurt. Therefore, Humatrope 24 mg cartridge 2.2 mg cartridge is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 35-year-old female enrollee has requested authorization and coverage for brand name Qudexy XR 200 mg at the frequency of three capsules per day. The Health Insurer has denied this request indicating that the requested medication dosage is not medically necessary for treatment of the enrollees chronic migraines.  The physician reviewer found the request for brand name Qudexy XR 200 mg at the frequency of three capsules per day is not medically necessary for treatment of the patients medical condition. In this case, the patient presents with chronic headaches. There is a lack of documentation supporting a diagnosis of migraine. She also has history of seizures, but the records do not indicate the semiology of her seizures, response to current therapy, or previously utilized agents. The patient has marked allergies to various binders and other parts of the generic topiramate tablets. The U.S. Food and Drug Administration (FDA) has approved Qudexy dosing up to 400 mg per day for adults with generalized seizures and partial onset seizures, and studies show dosing above that does not add efficacy. The FDA recommended dose for migraine is 100 mg once per day, and in the initial clinical trials, was not effective at higher doses. As such, the requested medication dosage has not been established as medically necessary for treatment of the patients medical condition. Therefore, the requested medication dosage is 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 46-year-old female enrollee has requested authorization and coverage for breast reconstruction surgery.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee, who is status post breast implant placement. The physician reviewer found the patient is status post bilateral augmentation mammaplasty for apparent aesthetic reasons.  Following traumatic injury, she had significant shoulder pain and weakness related to a neuropathy.  She has undergone reconstructive procedures in order to improve the function of her shoulder, as well as physical therapy.  Multiple providers have recommended implant removal or breast reduction to allow for improved function.  However, the plastic surgery recommendation is for reducing the implant size by 50 cc, performing a mastopexy, and placing a Xenograft.  These procedures are not medically necessary.  However, as the implant size of 350 cc may be contributing to her chronic pain and functional impairment, implant removal may provide improved relief given failure of other treatment.  Therefore, as the patients functional impairment from a previous traumatic injury may improve with implant removal, removal of implants is medically indicated.  No other surgical intervention would likely provide reasonable improvement.  Therefore, a portion of the requested services is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 65-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 1a. The physician reviewer found according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic genotype 1 hepatitis C regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. In conclusion, the requested medication is 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 56-year-old female enrollee has requested authorization and coverage for Botox injection. 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 the submitted documentation supports the medical necessity of the requested services. Cervical dystonia is an involuntary movement disorder characterized by uncontrolled muscle contraction, often with pain, altered range of motion, and altered head position. This condition can result in headache and neck pain. Spasmodic torticollis is synonymous with cervical dystonia. It is typically idiopathic, but in some cases results from injury. In this patients case, the records noted neck pain, headache of non-migraine character, and limited neck range of motion. Her presentation is consistent with cervical dystonia. The U.S. Food and Drug Administration has approved the use of Botox injections in this clinical setting. Botulinum toxin injections are medically appropriate for the treatment of this patient. Therefore, the requested Botox injection is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 63-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 10/21/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the breast tomosynthesis performed on 10/21/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The advantage of tomosynthesis relates to the ability often afforded the reader in being able to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. For this reason, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the exam been done with two-dimensional technique alone. 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 63-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 10/21/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that there is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. According to the study by Ciatto and colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis (Skaane, et al). Given the support above, the breast tomosynthesis performed on 10/21/15 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 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 63-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 10/21/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the breast tomosynthesis performed on 10/21/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is a lack of peer-reviewed literature that supports the use of digital breast tomosynthesis compared to currently available techniques. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in peer-reviewed literature. Accordingly, the breast tomosynthesis performed on 10/21/15 was not likely to provide this patient with an improved health outcome when compared to standard available techniques. 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 

A 63-year-old female enrollee has requested authorization and coverage for dental services. The Health Insurer has denied this request indicating that the requested services are not medically necessary for the treatment of the enrollees dental condition. The physician reviewer found that treatment for accidental injury is medically necessary when treatment is required due to accidental damage, with coverage for crowns when the service is the only clinically acceptable treatment alternative. Clinical records from prior to the accident and immediately following the accident do not demonstrate significant damage to the teeth, with the exception of the tooth fracture on number 7, which clinical records would indicate could be repaired successfully with a conventional bonded restoration. With a history of periodontal disease, the literature supports that even when treated and stabilized, mobility would be expected due to the loss of supporting alveolar bone. Aesthetic concerns include the existence of super eruption of tooth number 8 related to the patients history of periodontal disease, as well as rotations and malocclusion existing at the time of the accident.  These findings would demonstrate that the treatment requested is, to a significant extent, to address structural and aesthetic issues related to existing periodontal disease and malocclusion and not in treatment of injury related to the patients fall, as the only substantial damage related to the fall was the incisal fracture of number 7 noted above. Therefore, the requested dental services are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 47-year-old female enrollee has requested reimbursement for back surgery (lumbar spine fusion) performed on 9/3/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees back pain.  A review of the record indicates that the enrollee has a history of low back pain. The enrollee reported that she was involved in a motor vehicle accident in 2011. The enrollee has had conservative therapies with multiple providers to relieve her back pain. Objective findings include radiographic and diagnostic evaluations. The enrollee has requested reimbursement for a back surgery performed on 9/3/14.
The Health Insurer indicates that the documentation provided did not meet the Health Insurers clinical criteria for the services at issue. Therefore, reimbursement for the back surgery was denied.  At issue in this case is whether the services at issue were medically necessary for treatment of the enrollees medical condition.I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Insurers denial should be upheld.