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

Summary Reviewer 1


A 62-year-old male enrollee has requested authorization and coverage for positron emission tomography (PET) scan.  The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the requested services in this clinical setting.  The medical evidence supports up to three PET scans for all solid tumors including multiple myeloma for staging, restaging and surveillance.  Per the current guidelines, the most sensitive imaging test to detect active or recurrent myeloma is positron emission tomography/computed tomography (PET/CT).  Thus, the requested PET scan is likely to be superior over other modalities for evaluating this patient.  Based upon the information set forth above, the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 62-year-old male enrollee has requested authorization and coverage for positron emission tomography (PET) scan.  The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the requested services in this clinical setting.  Nanni and colleagues noted that evaluation of multiple myeloma bone disease at diagnosis should include both magnetic resonance imaging (MRI) of the spine and (18)F-FDG positron emission tomography/computed tomography (PET/CT).  Zamagni and colleagues noted that PET/CT may provide additional and valuable information for the assessment of myeloma bone disease in areas not covered by MRI.  Therefore, the requested PET scan is likely to be of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 62-year-old male enrollee has requested authorization and coverage for positron emission tomography (PET) scan.  The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found multiple myeloma is a cancer of plasma cells.  In multiple myeloma, collections of abnormal plasma cells accumulate in the bone marrow, where they interfere with the production of normal blood cells.  Most cases of multiple myeloma exhibit severe anemia.  In addition, these patients will occasionally develop soft tissue tumors composed of abnormal plasma cells.  The hallmark means to diagnose multiple myeloma is via laboratory demonstration of abnormal levels of specific proteins via electrophoresis.  Nonsecretory myeloma is a myeloma subset which is generally characterized by demonstration of monoclonal plasma cells in the bone marrow but with negative results on serum and urine electrophoresis.  In these patients, anemia is less common and renal impairment is rare.  Most of these patients present with symptomatic bone lesions.  As noted by Lonial and Kaufman, imaging with positron emission tomography/computed tomography (PET/CT) scans, and minimal residual disease (MRD) assessment with multi-parameter flow cytometry, may provide newer methods for response assessment, something that has been severely limited in these patients due to the lack of a reliable biomarker. Per the medical evidence, PET scan is a valuable means to evaluate and stage myeloma patients.  Thus, the requested PET scan is likely to be of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 68-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/06/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines indicate that 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 trial. 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, and 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 performed on 12/06/17 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 68-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/06/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that 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 to these statistics. DecisionDx-Melanoma testing is an assay of 31 genes in an individuals melanoma cells. It then classifies that melanoma based on the five-year risk of metastasis. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients undergoing sentinel node biopsy. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the 10-year Balch data. Furthermore, it is not clear if the DecisionDx-Melanoma assay classification can be used to make clinical decisions. In sum, DecisionDx-Melanoma testing performed on 12/06/17 was not likely to have been more efficacious than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 68-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/06/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. The test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing performed on 12/06/17 was not likely to have been more effective than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 23-year-old female enrollee has requested reimbursement for continued stay at partial hospital substance use disorders treatment provided from 9/27/17 through 10/01/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The progress notes indicated that the patient was cooperative in treatment. The progress notes for the disputed timeframe indicate that the patient was attentive during group discussions and was engaged in therapy discussions. Per the records, this patient could have received effective treatment on an intensive outpatient basis or outpatient basis. She was motivated for treatment with mention of insight into her illness as well as documentation of her knowledge of skills to maintain sobriety. The supplied documentation does not indicate that she was having severe mood swings or other severe psychiatric symptoms. In cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. With regards to risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. In terms of functional status, the records support a score of 2 or 3 due to the loss of her job prior to treatment and continued substance use. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability. In terms of level of stress of the recovery environment, the records support a score of 3. There was mention of being homeless on admission due to substance use. With regards to level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources. In terms of treatment and recovery history, the records support a score of 3. The treatment progress notes indicate that she had good progress and participation in her partial hospitalization program treatment. With regards to engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into her need for treatment. Thus, the patient has a composite score of 15 or 16. This score correlates with the community-based outpatient clinic setting. In sum, the patient could have been treated in a less restrictive setting. All told, continued stay at partial hospital substance use disorders treatment provided from 9/27/17 through 10/01/17 was not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

The patient is a 16-year-old male with a history of mood dysregulation disorder, attention deficit/hyperactivity disorder, cannabis use disorder, and hallucinogen use disorder. The patient was admitted to an intensive outpatient program on 12/15/17 due to angry outbursts, substance use, and emotional dysregulation. The patient was treated with individual, family, and group psychotherapy along with medication management. The Health Insurer has denied reimbursement and prospective authorization and coverage for mental health intensive outpatient treatment provided from 2/17/18 forward. Per the Health Insurer, the services at issue were not and are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The Child and Adolescent Level of Care Utilization System (CALOCUS) is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 2. The patient had chronic passive suicidal ideation with no intention or plan. There is no documentation of prior suicide attempts. With regards to functional status, the records support a score of 3. The patient has conflicted relationships with his peers and family. During the intensive outpatient program treatment, the patient has had problems focusing when asked to complete assignments. He will resist encouragements to complete assignments. He has chronic severe deficits in interpersonal relationships, and he has severe deficits in his ability to engage in socially constructive activities. In terms of comorbidity, the records support a score of 3. The patient has comorbidities of mood dysregulation disorder, attention deficit/hyperactivity disorder, cannabis use disorder, and hallucinogen use disorder. With regards to environmental stress of the recovery environment, the records support a score of 3. The patient has chronic interpersonal conflicts with his parents. He has angry outbursts at home. In terms of environment support, the records support a score of 3. With regards to resiliency, the records support a score of 3. The patient has made minor improvements during his intensive outpatient program treatment, such as remaining sober. However, he continues to be irritable, angry, easily agitated, and resistant to treatment. In terms of acceptance and engagement, the records support a score of 3. On many occasions, the patient has not cooperated with treatment. He is easily agitated and frequently irritable. Thus, the records support a composite score of 20. Based on these criteria, the patient meets criteria for continued intensive outpatient program treatment. Therefore, mental health intensive outpatient treatment provided from 2/17/18 forward was and is medically necessary for the treatment of this patient. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 51-year-old female has requested reimbursement for human epididymis protein 4 (HE4) testing.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this patients case.  HE4 is used for the evaluation of an adnexal mass as a component of the Risk of Ovarian Malignancy Algorithm (ROMA). A ROMA score helps determine the likelihood that an adnexal mass is malignant and the need for referral to a gynecologic oncologist for surgery. This testing is considered a standard of care.  In sum, HE4 testing performed on 11/20/15 was likely to have been of greater benefit 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 Upheld

Summary Reviewer 2


A 51-year-old female has requested reimbursement for human epididymis protein 4 (HE4) testing.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  There were no progress notes, physical examinations or laboratory testing detailing the patients medical condition.  Although the records note a complex ovarian mass, details regarding the rationale for the testing were not provided.  In sum, HE4 testing performed on 11/20/15 was 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 3


A 51-year-old female has requested reimbursement for human epididymis protein 4 (HE4) testing.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the evaluation of the symptomatic patient with pelvic/adnexal mass includes physical examination and may include transvaginal ultrasonography and measurement of levels of the serum tumor marker CA125. HE4 tumor markers are not recommended to help make the decision as to whether an adnexal mass represents a benign or malignant process. The results should not be used in the decision-making process of which patients should have additional surgical evaluation of an adnexal mass. Tumor marker panels have not been evaluated prospectively in large population-based studies and have not been proven to improve early detection and survival rates.  In sum, HE4 testing performed on 11/20/15 was not likely to have been superior over other modalities for 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 Overturned

Summary Reviewer 1


A 48-year-old female enrollee has requested reimbursement for a breast tomosynthesis that was performed on 11/25/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for purposes of the enrollees breast cancer screening. The physician reviewer found medical studies have shown that the addition of three dimensional (3D) digital breast tomosynthesis (DBT) reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography (FFDM, 2D) alone. Recall rates are reduced by 15-17%: 3D allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue (asymmetries). Studies have also shown that there has been an increase in cancer detection by 33-53%: cancer detection increased from 6 cancers/1000 women screened with 2D to 8 cancers/1000 women screened with 3D. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion.  In sum, there is sufficient evidence supporting the use of tomosynthesis for routine breast cancer screening. Thus, the breast tomosynthesis performed on 11/25/15 was likely to be more beneficial for this patient than any available standard modalities. 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 48-year-old female enrollee has requested reimbursement for a breast tomosynthesis that was performed on 11/25/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for purposes of the enrollees breast cancer screening. The physician reviewer found per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Medical studies and peer reviewed literature support the use of tomosynthesis in this clinical setting.  For these reasons, the tomosynthesis used to screen this patient for breast cancer was likely to be more beneficial 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 48-year-old female enrollee has requested reimbursement for a breast tomosynthesis that was performed on 11/25/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for purposes of the enrollees breast cancer screening. The physician reviewer found breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts (Helvie). In this particular patient, she has dense breasts. While one could make the argument that her mammogram has not changed since the prior studies, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In this clinical setting, where the patient presents with dense breast tissues, the tomosynthesis was likely to be more beneficial as a screening tool than standard modalities including breast sonography. 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 1

The parent of a 14-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 10/7/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the Prometheus Anser IFX diagnostic testing performed on 10/7/14 was likely to be more effective for this patient than other available treatment options. The testing at issue has become the standard of care for providers to determine whether the patient will benefit from the drug. Prometheus Anser IFX testing informs the provider if the serum levels of drug are in the range to be beneficial and effective or if they have antibodies that could potentially lead to a reaction or failure to respond. This helps guide the provider in dosing or may lead to discontinuation of the drug if the patient is not likely to benefit from the medication. This prevents the patient from having a flare-up and also prevents potential side effects of a drug the patient may not benefit from. In this case, the patient appeared to be losing response to Remicade and Prometheus Anser IFX testing allowed for the provider to determine if antibodies are present or if the patient needs a higher dose of the medication to prevent from a flare-up with further consequences. Therefore, the Prometheus Anser IFX testing was appropriate for the management of the patients Crohns disease and 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.