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

Summary Reviewer 1

A 52-year-old male enrollee has requested reimbursement for proton beam therapy provided from October through December 2016. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees nasopharyngeal carcinoma. The physician reviewer found that there is a lack of clinical data in the medical literature to suggest that treatment with proton beam radiation offers a superior clinical benefit when compared to conventional radiation therapy techniques for tumors of the head and neck area. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy (IMRT). A recent comparative analysis found no significant difference in symptom burden in the acute and chronic phases of treatment with proton therapy was compared to photon therapy for head and neck cancer (Sio).   Also, the ASTRO emerging technology committee report on proton beam therapy specifically states that there is insufficient data to recommend proton beam therapy for routine head and neck radiation therapy outside of clinical trials (Allen, et al). The comparative planning was reviewed and showed no clinically significant benefit with treatment with proton therapy over standard photon techniques as all standard dose metrics are met with the photon plan. In sum, the proton beam therapy provided from October through December 2016 were not likely to have been more efficacious than the standard options available to evaluate this patient. Therefore, for the reasons stated above, the services at issue were not likely to be more beneficial for treatment of this 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 52-year-old male enrollee has requested reimbursement for proton beam therapy provided from October through December 2016. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees nasopharyngeal carcinoma. The physician reviewer found that currently, there is insufficient data to suggest the superior efficacy of proton beam therapy in this clinical setting. At this time, further data through prospective clinical trials is needed regarding cases in which the target is the primary volume located near critical structures. Whether or not proton therapy (in general) affords any benefit over conventional radiation therapy is a controversial issue with quite disparate opinions among experts in the field. The medical literature suggests that the benefit from proton beam therapy is primarily in the head and neck cancers in which the target directly abuts critical structures like skull base tumors. There are preliminary dosimetric studies, which suggest that proton beam therapy may be better at sparing pharyngeal constrictor muscles spinal cord, parotid glands, larynx, and brainstem. However, the issue of whether dose reduction to any of these structures beyond what intensity modulated radiation therapy (IMRT) can achieve, is still undecided. For most head and neck cancers, IMRT should be able to readily spare the salivary glands, pharyngeal constrictors, spinal cord, brainstem, mandible and other normal tissues. The medical evidence for sinonasal tumors is encouraging, but further data is needed. As such, proton beam therapy provided from October through December 2016 was not likely to have been superior to IMRT or other standard modalities for evaluating this patients medical condition.  Therefore, for the reasons stated above, the services at issue were not likely to be more beneficial for treatment of this 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 52-year-old male enrollee has requested reimbursement for proton beam therapy provided from October through December 2016. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees nasopharyngeal carcinoma. The physician reviewer found that based on review of available data, proton beam therapy in the treatment of nasopharyngeal carcinoma is superior to the standard alternatives available.
While there are no randomized trials evaluating the use of proton beam therapy for nasopharyngeal carcinomas, its Bragg Peak, proton beam therapy will always appear dosimetrically superior (Lewis 2016). For any given site, whether or not this dosimetric benefit translates into a clinical benefit is uncertain, but such a benefit exists for nasopharyngeal carcinoma. The treatment of skull-based tumors is a well-accepted use of proton therapy. It is the prototypical site used to demonstrate the ability of proton therapy to spare adjacent cranial nerves in a tight space to a high precision. The most common histology of skull-based tumors are chordomas and chondrosarcomas. According to the ASTRO Model Policy on Proton Beam Therapy, on the basis of [the above] medical necessity requirements and published clinical data, disease sites that frequently support the use of PBT include  tumors that approach or are located at the base of skull, including but not limited to chordoma and chondrosarcomas. Due to the fact that the typical nasopharyngeal carcinoma radiation field includes the base of skull by definition (RTOG 0615), and that the dose required to treat nasopharyngeal cancer is higher than needed for a chordoma, proton therapy would also be beneficial for the treatment of nasopharyngeal cancer. Additionally, the optic nerves and chiasm are typically adjacent to the treatment volume for nasopharyngeal carcinoma. These structures typically limit the nasopharynx from receiving the full prescribed dose of radiotherapy, whereas proton beam therapy would allow full treatment of these areas. Based on the above, proton beam therapy provided from October through December 2016  was the superior modality for the treatment of  this patients medical condition. Therefore, for the reasons stated above, the services at issue were likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 58-year-old male enrollee has requested reimbursement for Oncotype DX Prostate Cancer Assay performed on 11/13/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer.  The physician reviewer found that the patient is a 58-year-old male who was diagnosed with prostate cancer on 10/18/17. At that time, he was found to have a Gleason 3+4=7 adenocarcinoma in four of 12 cores. The patient has requested reimbursement for Oncotype DX Prostate Cancer Assay performed on 11/13/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. There currently are three major options for the management of localized prostate cancer. These include surgery, various forms of radiation therapy, and active surveillance. Recommendations as to these options are based on risk stratification, which estimates the risk of the future development of progressive cancer. Various features of an individuals cancer are put into this assessment, particularly the prostate-specific antigen (PSA) level, clinical stage, and pathologic details of the cancer. A further refinement of such prognostics is the use of gene panels, such as Oncotype DX Prostate Cancer Assay. This is a 17-gene panel that may assist in predicting recurrence after treatment for prostate cancer. There is sufficient support for the services at issue in this clinical setting. Therefore, Oncotype DX Prostate Cancer Assay performed on 11/13/17 was likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 58-year-old male enrollee has requested reimbursement for Oncotype DX Prostate Cancer Assay performed on 11/13/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer.  The physician reviewer found that the patient is a 58-year-old male who was diagnosed with an intermediate risk prostate cancer on 10/18/17. This is based on an elevated prostate-specific antigen level and a Gleason score of 3+4=7. The tumor involved four of 12 cores. The patient has requested reimbursement for Oncotype DX Prostate Cancer Assay performed on 11/13/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. The medical evidence supports the services at issue in this patients case. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network (NCCN) risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays. It is considered a standard of care in guiding treatment decision making. In sum, Oncotype DX Prostate Cancer Assay performed on 11/13/17 was likely to have been superior over other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 58-year-old male enrollee has requested reimbursement for Oncotype DX Prostate Cancer Assay performed on 11/13/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer.  The physician reviewer found that the patient is a 58-year-old male with a history of elevated prostate-specific antigen level. On 10/18/17, pathology report noted prostatic adenocarcinoma, Gleason score 3+4=7. The tumor involved four of 12 cores. The patient has requested reimbursement for Oncotype DX Prostate Cancer Assay performed on 11/13/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. The medical evidence has not established the superior effectiveness of the services at issue in this clinical setting. This testing has not been validated with prospective randomized clinical trials to change outcomes and impact survival or quality of life. There is a lack of support for the use of this molecular test to determine the appropriateness of observation or active surveillance. Thus, Oncotype DX Prostate Cancer Assay performed on 11/13/17 was not likely to be of greater benefit 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 1

A 60-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 7/01/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that there is a lack of support for the services at issue in this setting. Prognostic gene expression profiling (GEP) testing to differentiate melanomas at low versus high risk for metastasis should not replace pathologic staging procedures. Moreover, since there is a low probability of metastasis in stage I melanoma and a higher proportion of false-positive result, GEP testing should not guide clinical decision making in this group. Commercially available GEPs, such as DecisionDx-Melanoma testing, are marketed as being able to classify cutaneous melanoma into separate categories used on risk of metastasis. However, it remains unclear where these GEP platforms provide clinically actionable prognostic information when used in addition to or in comparison with known cliniopathologic factors or multivariate nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. Various (mostly retrospective) studies of prognostic gene expression profiling (GEP) testing suggest its role as an independent predictor of worse outcome, although not superior to Breslow thickness or sentinel lymph node status. It remains unclear whether this GEP profile is reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation studies (as have been performed in breast cancer) are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Therefore, DecisionDx-Melanoma testing performed on 7/01/20 was not likely to have been more beneficial than other available standard therapy
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 60-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 7/01/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas 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 may add to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individualas melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami reported on 217 cases, with good correlation between DecisionDx-Melanoma testing class and prognosis in patients undergoing sentinel node biopsy. It is not known how the five-year DecisionDx-Melanoma testing data compares to the ten-year Balch data. It is not known if the DecisionDx-Melanoma testing data can be used to make clinical decisions. The National Comprehensive Cancer Network does not recommend the test to make decisions. Therefore, DecisionDx-Melanoma testing performed on 7/01/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 60-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 7/01/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas 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 the DecisionDx-Melanoma testing for melanoma 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. Therefore, DecisionDx-Melanoma testing performed on 7/01/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a 16-year-old male enrollee has requested authorization and coverage for private duty nursing. The Health Insurer has denied this request and reported that the requested services are not medically necessary for treatment of the enrollee, who has been diagnosed with spinal muscular atrophy. The physician reviewer found the submitted documentation supports the medical necessity of the requested services.  Spinal muscular atrophy is an autosomal recessive progressive disorder with multiple phenotypic presentations. Children with this diagnosis are typically severely disabled and wheelchair-bound. Scoliosis and severe gastroesophageal reflux eventually occur, with risk for aspiration, pneumonia, and malnutrition. Intelligence is generally normal. This patient with spinal muscular atrophy has a number of skilled nursing needs as detailed above. He is at risk for aspiration with resultant pneumonia and skin breakdown. He requires aggressive respiratory care, including airway clearance to prevent pneumonia, close observation during feeding to prevent aspiration, and assistance with all aspects of daily living, including application of supplemental oxygen and administration of medications. Based on his current clinical situation, the requested private duty nursing is medically necessary. Therefore, the requested services are 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 five-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 15 additional hour per week of applied behavior analysis (total of 40 hours per week) from 1/16/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically for treatment of the enrollees medical condition. The physician reviewer found that ABA has been shown in the medical literature to be effective for children with autism spectrum disorders. However, the medical research is inconclusive on the amount of hours of ABA indicated for patients in this clinical setting. In addition, there is a lack of head-to-head studies comparing 40 hours per week of ABA services to 25 hours per week. Reichow and colleagues found that early intensive behavioral intervention (EIBI) was effective for treating children with autism and the average amount of ABA therapy was 25 hours per week. In this case, the data provided for review demonstrates that the patient has been making progress with 40 hours per week of ABA therapy. However, there is a lack of documentation showing regression, increase in behaviors or worsening problems due to a decrease in ABA services. In the absence of documentation demonstrating the patient has made slower progress or had a regression with a decrease in ABA services, the services at issue have not been established as medically necessary for treatment of the patients medical condition. Therefore, the services at issue were not and 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 

The patient is a 63-year-old female with a history of hypertrophic cardiomyopathy, non-sustained ventricular tachycardia. The patient has requested reimbursement for telemetry level of care provided from 3/13/20 through 3/16/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that this patient had severe hypertrophic cardiomyopathy and known non-sustained ventricular tachycardia. At baseline, this patient is at a significantly higher risk for life threatening rhythm disturbances. Postoperatively, with the attendant injury and edema to the septal myocardium along with the marked electrolyte shifts of the postoperative period, she would be at even higher risk for life threatening rhythm disturbances. Maintaining her in a cardiac telemetry monitored situation was medically necessary given the underlying arrhythmic substrate of her cardiomyopathy, coupled with the various surgical stresses. She had documented ventricular tachycardia postoperatively noted on the telemetry monitor and atrial fibrillation with rapid ventricular response, both of which required immediate treatment in the perioperative period. Given her elevated risk of a life threatening arrhythmia, she was also not considered for discharge until an AICD had been implanted, making the necessity of postoperative cardiac monitoring all the more important. Therefore, telemetry level of care provided from 3/13/20 through 3/16/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 67-year-old male enrollee has requested reimbursement for HCPCS J0775, clostridial collagenase histolyticum injections provided on 11/07/16 and 11/10/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees Peyronies disease. The physician reviewer found that Peyronies disease is caused by scar tissue, called plaque, which forms along the length of the penis in the corpora cavernosa. This plaque is not visible, and depending on the severity of the condition, this condition can cause penile curvature with erection. The curvature can make intercourse difficult and/or painful for the patient and his partner. Potential treatments for Peyronies disease include surgery, minimally invasive treatment options, and medications. The results for most previously available medications and minimally invasive therapies have been inconsistent or lacked empirical support for effectiveness. The medical evidence supports the services at issue in this clinical setting. Thus, HCPCS J0775, clostridial collagenase histolyticum injections provided on 11/07/16 and 11/10/16 were medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.