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

Summary Reviewer 

A 68-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/03/18 and 10/16/18. The Health Insurer has denied this request and reported that the service at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had several early stage melanomas. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. 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. Therefore, DecisionDx-Melanoma testing provided on 10/03/18 and 10/16/18 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 
The patient is a 72-year-old male with a history of oligometastatic adenocarcinoma of his prostate gland, with disease recurrence in his left internal iliac nodal chain. The patient has requested authorization and coverage for robotic stereotactic body radiation therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this clinical setting. Aggressive local treatment of oligometastatic disease has been associated with improvement in survival. This patient has locoregionally-confined disease, which is technically curable. He would not be a great candidate for salvage surgery, given the prior operation and likely presence of extensive adhesions. Furthermore, systemic therapy would not be a curable treatment option. External beam radiotherapy (in the form of intensity modulated radiation therapy or stereotactic body radiation therapy) represents his best chance for cure. In this setting, stereotactic body radiation therapy is supported by the National Comprehensive Cancer Network (NCCN) guidelines as well as the American Society for Radiation Oncology (ASTRO) Model Policy. Therefore, robotic stereotactic body radiation therapy is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 62-year-old male enrollee has requested authorization and coverage for sodium fluoride (NaF) 18 positron emission tomography (PET) with computerized tomography (CT), whole body scan. The Health Insurer has denied this request indicating that the requested services not medically necessary for evaluation of the enrollees prostate cancer. The physician reviewer found that there is support in the medical literature for the requested PET/CT scan in this clinical setting. The documentation indicates that this patient is highly at risk for bone metastasis and his rising PSA is concerning for additional skeletal metastases besides the treated T-12 lesion.  It has been well documented in the medical literature that NaF 18 is far more sensitive than technetium 99M bone scan agents in the detection of metastatic disease to bone in patients with prostate cancer. This patient had a previous NaF 18 PET/CT scan that located his metastatic lesion that was not appreciated on the technetium scan earlier.  Thus, the PET/CT using the more sensitive compound will represent the baseline study with which to compare for progressive metastatic bone disease. All told, NaF 18 PET/CT, whole body scan is medically necessary for the evaluation of this patients medical condition. Therefore, for these reasons, the requested services are medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

excavatum. Removal of the bars was performed 6/21/19. The procedure consisted of exposing the bars through the capsules bilaterally on two bars and extracting the bars after straightening. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. Cohen and colleagues noted that Large volume hemorrhage after Nuss bar removal is rare, but may require blood transfusion, thoracoscopic exploration, or open exploration through thoracotomy or sternotomy. Nuss bar removal should be performed in centers capable of these interventions. Bilgi and colleagues stated that Major complications after removal of the Nuss bar occur with some frequencyImmediate management of the complications may require multidisciplinary care. Because of the significant risk of significant complication requiring immediate surgical correction following double Nuss bar removal, the use of an assistant during surgery was medically indicated. Therefore, assistant surgeon services (21899-80) provided on 6/21/19 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The patient is a 57-year-old male with a history of AL amyloidosis with cardiac involvement. Computed tomography (CT) imaging of the pelvis with contrast on 12/21/16 for a history of amyloid light chain amyloidosis revealed stable small pericardial effusion and bilateral renal cysts, unchanged from 5/27/16. The provider reports the patient has been treated with Cytoxan, dexamethasone, Velcade, and Kyprolis. The providers treatment plan is to start Darzalex if these medications are not effective. The patient has requested authorization and coverage for daratumumab (Darzalex). The Health Insurer has denied this request indicating that the requested medication is considered investigational. As reported in the peer-reviewed medical literature, Darzalex was tested in previously treated patients with systemic amyloidosis in two phase II studies (Roussel, et al; Sanchorawala, et al). In these studies, hematologic response rates were approximately 60%, with positive organ responses, and reductions in serum free light chain levels. Given this support, the requested Darzalex is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication is 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 Overturned

Summary Reviewer 2

The patient is a 57-year-old male with AL amyloidosis with cardiac involvement. Prior treatment has included Cytoxan, dexamethasone, Velcade, and Kyprolis. The provider has recommended treatment with daratumumab (Darzalex). The patient has requested authorization and coverage for Darzalex. The Health Insurer has denied this request indicating that the requested medication is considered investigational. As noted in the medical literature, Darzalex is an anti-CD38 monoclonal antibody used in multiple myeloma. Case reports and a retrospective study described the safety and efficacy of daratumumab in patients with relapsed or refractory AL amyloidosis (Sher, et al; Kaufman, et al). Toxicity was similar to that observed in patients with multiple myeloma. All told, the requested Darzalex is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication is 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 Overturned

Summary Reviewer 3

The patient is a 57-year-old male with amyloidosis. He was diagnosed with AL amyloidosis caused by a kappa light chain plasma cell neoplasm. His disease manifestations included restrictive cardiomyopathy, syncope, dyspnea, carpal tunnel syndrome, and dysrhythmia. He was treated with bortezomib, cyclophosphamide, and dexamethasone. His free light chains increased after this treatment suggesting progressive disease. The patient has requested authorization and coverage for daratumumab (Darzalex). The Health Insurer has denied this request indicating that the requested medication is considered investigational. Primary amyloidosis due to immunoglobulin light chains and multiple myeloma are both plasma cell neoplasms. Both diseases are the result of cancerous plasma cells that are secreting paraproteins. In AL amyloidosis, the plasma cells involving the bone marrow are fewer in number than in multiple myeloma and the light chains have the protein characteristic of forming amyloid in tissues. In this case, there is no standard approach. Darzalex is a monoclonal antibody directed against CD38. It was approved by the U.S. Food and Drug Administration (FDA) for treatment of myeloma in patients who have progressed on proteasome inhibitor or immunomodulatory agents. Moreover, Darzalex has been shown to be effective against AL amyloidosis (Kaufman, et al). For these reasons, the requested Darzalex is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 10-year-old female enrollee has requested authorization and coverage for Humatrope 24 mg cartridge. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees short stature.  A review of the record indicates the enrollee has a history of short stature. Per the provider, the enrollees height dramatically improved at the time she started human growth hormone in November 2014. Since starting growth hormone and catching up her growth, the enrollees development and confidence have improved. Prior to treatment, the enrollees growth chart showed she was in the 1.2 percentile which is 2.25 standard deviations below average. The records note the enrollee has a mid-parental height (MPH) of 5 feet 5.5 inches, and was more than two standard deviations below her mid-parental height.  The Health Insurer indicates the requested medication is not medically necessary for treatment of the enrollees medical condition.  At issue in this case is whether the requested medication is medically necessary for treatment of the enrollees medical condition. I have determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 17-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation device. The Health Insurer has denied this request and reported that the requested device is not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation supports the requested device in this clinical setting. This patient has a history of chronic migraine which evolved into chronic daily headache following three concussions. She has had inadequate symptom relief from both prophylactic and acute abortive medications, together with a variety of non-pharmacologic therapies. She has had an excellent response to transcranial magnetic stimulation, with a decrease in her headache frequency from daily headaches to two to four headaches per month. Irwin and colleagues conducted an open-label prospective pilot feasibility study of single-pulse transcranial magnetic stimulation (sTMS) for migraine prevention in adolescents aged 12-17 years. Participants used sTMS twice daily in a preventative fashion, as well as additional pulses as needed acutely. A four-week baseline run-in period (weeks 1-4) was followed by a 12-week treatment period. The authors concluded that sTMS appears to be a feasible, well-tolerated, and acceptable nonpharmacologic preventive treatment for migraine in adolescents. There is sufficient support for the requested device in this clinical setting. Therefore, the requested transcranial magnetic stimulation device is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1
The parent of a three-year-old female enrollee has requested authorization and coverage for homocysteine, Factor V Leiden, and methylene tetrahydrofolate reductase (MTHFR), testing performed on 6/4/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee whose parent was diagnosed with idiopathic venous embolism and was positive for the MTHFR mutation and Factor V Leiden deficiency. The physician reviewer found that the documentation provided does not support the efficacy of the services at issue in this clinical setting. The medical literature suggests those who have idiopathic thromboembolism before the age of 45 years or at an unusual site may request homocysteine testing. While this may be the case for the patients mother, it is not the case for the patient herself. The American College of Medical Genetics and Genomics (ACMG) has prepared guidelines for FVL testing. This patient may have relatives diagnosed with FVL, but the patients mother is not diagnosed with this medical condition. This would indicate that this patient is not at risk for inheriting FVL from her. While the patient could inherit FVL from her father, there is no report of clotting disorder or FVL in the paternal family history. Moreover, this patient has not had a blood clot. With regards to MTHFR, ACMG recommends against testing for MTHFR polymorphisms in any patient, including in those with relatives with known MTHFR polymorphisms. The literature suggests that there is no risk associated with the A1298C polymorphism in the heterozygous or homozygous state. Further, it could have been predicted that this patient would have at least one copy of A1298C as her mother is homozygous. ACMG guideline suggests testing of homocysteine could be reasonable only in those with two copies of the C677T polymorphisms. In this clinical setting, this is not possible for this patient based on his mother's testing. In sum, homocysteine, FVL, and MTHFR tests performed on 6/4/16 were not likely to have been more beneficial than standard options for the evaluation of this patient. Therefore, for the reasons stated 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
The parent of a three-year-old female enrollee has requested authorization and coverage for homocysteine, Factor V Leiden, and methylene tetrahydrofolate reductase (MTHFR), testing performed on 6/4/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee whose parent was diagnosed with idiopathic venous embolism and was positive for the MTHFR mutation and Factor V Leiden deficiency. The physician reviewer found that according to the records, the services at issue were not likely to have been beneficial to this patient. The patients mother tested negative for the FVL mutation. As such, testing the patient, who was asymptomatic, was not indicated. Further, the patients mother was the only person in the family with thrombosis and she tested negative for this mutation. Though the patients mother has had blood clots at an early age and in unusual places, the patient herself is not reported to have thrombosis. The American College of Medical Genetics (ACGM) has a practice guideline regarding genotyping of MTHFR. Studies of MTHFR have been plentiful and have focused on a wide variety of conditions, including vascular disease, neural tube defects, mental illness, autism, and cancer, to name a few. However, after a comprehensive review, ACMG found that there is insufficient evidence for the clinical utility of MTHFR polymorphism testing. The ACMG guidelines do not recommend testing for MTHFR.  In this patients case, the records do not support that this test provided any clinical utility. All told, homocysteine, FVL, and MTHFR testing performed on 6/4/16 was not likely to have been more effective than other standard modalities for the evaluation of this patient. Therefore, for the reasons stated 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

The parent of a three-year-old female enrollee has requested authorization and coverage for homocysteine, Factor V Leiden, and methylene tetrahydrofolate reductase (MTHFR), testing performed on 6/4/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee whose parent was diagnosed with idiopathic venous embolism and was positive for the MTHFR mutation and Factor V Leiden deficiency. The physician reviewer found that While there is some support for the services at issue, the studies do not show that these tests have a clinical benefit to normal healthy children, as in this patients case.  The majority of pediatric deep venous thromboembolisms occur in hospitalized children with underlying medical conditions, such as prematurity, cancer, congenital heart disease, and infection. Most have multiple risk factors, the single most common being the presence of a central venous catheter. Outcomes from testing in the pediatric population include these types of screening are only recommended when it may alter therapy or result in targeted thromboprophylaxis. These screening tests are used in certain patients, if indicated. However, in this patients case, she does not fall within the suggested clinical indications. Instead, the available literature appears to suggest that for generally healthy children, the best approach is to delay testing until children are older. As such, homocysteine, FVL, and MTHFR testing performed on 6/4/16 was not likely to have been more efficacious than standard therapies available for the evaluation of this patient. Therefore, for the reasons stated 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 62-year-old female enrollee has requested reimbursement for substance abuse residential rehabilitation services provided from 2/17/14 through 3/29/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees alcohol dependence and major depressive disorder.  The physician reviewer found that due to multiple factors and unique considerations, determination of the appropriate level of care for patients with addictive disorders complicated by depressive illness and medical comorbidity is a challenging endeavor. Assisting with this process, the American Psychiatric Association (APA) guidelines state that residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. This patient had multiple medical problems including thyroid disease and chronic pain. She also had significant depression and had previously made a serious suicide attempt that prompted a one-to-one attendant until 3/3/14. During treatment, the patient received clinically appropriate care for her alcohol dependence and major depressive disorder. The comprehensive services were delivered in accordance with an individual treatment plan. Further, the services were reasonably expected to improve the patients condition and prevent a more serious episode of illness. The placement also provided opportunity for marital harmonization as her spouse attended the family program. Considering the clinical presentation and perusal of the peer-reviewed literature, residential placement with access to specialty services 24-hours a day was a safe, appropriate disposition consistent with good medical practice. Accordingly, the services at issue were medically necessary for treatment of the patients medical condition. In conclusion, 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 Overturned

Summary Reviewer 


A 34-year-old male enrollee has requested reimbursement for the chiropractic services provided from 5/17/14 through 7/5/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees neck pain, upper back pain and shoulder pain.   The physician reviewer found the records demonstrate that this patient had significant improvement in neck disability index and functional upper extremity index with chiropractic treatment provided from 5/17/14 through 7/5/14. The patient was returned to functional status after this course of chiropractic care. According to current medical research, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner. With the objective improvement, the chiropractic treatment sessions provided on 5/17/14, 5/19/14, 7/2/14, and 7/5/14 were appropriate and provided substantial improvement in this patients functional status. Thus, the chiropractic services provided from 5/17/14 through 7/5/14 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.