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

Summary Reviewer 2

A 71-year-old male enrollee has requested reimbursement ablation of the prostate, transrectal high intensity focused ultrasound (HIFU) including imaging guidance performed on 12/20/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee who has a history of prostate cancer. The physician reviewer found that the patient is a 71-year-old male with a history of prostate cancer (Gleason 7, T2c). He had high intensity focused ultrasound (HIFU) and had a rising prostate specific antigen (PSA). The patient has requested reimbursement for ablation of the prostate using transrectal HIFU including imaging guidance performed on 12/20/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for the treatment of the patient who has a history of prostate cancer. HIFU has been increasingly used for treatment of localized prostate cancer within the last decade. It has the theoretical potential of decreasing gastrointestinal, genitourinary and sexual toxicity. Potential candidates are patients with low to moderate risk prostate cancer. However, the available literature mainly consists of prospective case series and retrospective studies from Europe showing short to intermediate term outcomes for localized prostate cancer. As such, there is a lack of controlled trials available for analysis and very little long term survival data available. Additionally, there is a lack of validated biochemical and surrogate end point for cure. The National Comprehensive Cancer Network guidelines on prostate cancer state the following about focal therapy and HIFU, Other emerging local therapies, such as high intensity focused ultrasound (HIFU) and vascular-targeted photodynamic (VTP) also warrant further study. American Urological Association/American Society for Radiation Oncology/Society of Urologic Oncology guidelines note clinicians should inform low-risk prostate cancer patients who are considering focal therapy or high-intensity focused ultrasound (HIFU) that these interventions are not standard care options because comparative outcome evidence is lacking. Accordingly, the long term efficacy of the services at issue has not been established in this clinical setting. All told, transrectal HIFU including imaging guidance performed on 12/20/17 was not likely to have been more effective than other treatment options available for evaluating this patients medical condition. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 71-year-old male enrollee has requested reimbursement ablation of the prostate, transrectal high intensity focused ultrasound (HIFU) including imaging guidance performed on 12/20/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee who has a history of prostate cancer. The physician reviewer found that the patient is a 71-year-old male who was found to have elevated prostate specific antigen (PSA) in 2011. The patient underwent transrectal ultrasound and guided biopsy of his prostate at that time. He was found to have moderate risk prostate cancer with clinical stage T2c. He was consulted regarding treatment options. The patient elected high intensity focused ultrasound ablation of his prostate (HIFU) in 2011. Initially he did well; however, he had progressive elevation of his PSA. It was assumed that the patient had a recurrence. He again underwent ablation of the prostate using transrectal HIFU including imaging guidance performed on 12/20/17. The patient has requested reimbursement for the services at issue. The Health Insurer has denied this request for reimbursement and noted that the ablation of the prostate using transrectal HIFU including imaging guidance performed on 12/20/17 was investigational for the treatment of this patients medical condition.High-intensity focused ultrasound therapy for prostate cancer is a relatively new procedure. The U.S. Food and Drug administration has approved this procedure to be safe for treatment of prostate ablation. However, there is no specific indication for treatment for prostate cancer and there is no significant information regarding salvage therapy following HIFU. At this time, HIFU therapy for recurrent prostate cancer following initial treatment is not considered a standard of care in this clinical setting. Accordingly, transrectal HIFU including imaging guidance performed on 12/20/17 was not likely to have been more effective when compared to other treatment modalities for the treatment of this patients medical condition. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 61-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees colorectal cancer with liver metastases. The physician reviewer found that the American Society for Radiation Oncology (ASTRO) acknowledges the need for proton therapy when strongly justified by a dosimetric rationale such as specific dose-volume parameters for the target and nearby structures. Pelvic malignancies including gastrointestinal carcinomas are currently being evaluated and comparative efficacy evidence is being developed. In order for toxicity risks to be reduced, there should be a clinically significant reduction in dose to critical structures, with an evidence basis of benefit with dose reduction. However, the case records do not adequately demonstrate the need for proton therapy using dosimetric evidence. This is important in justifying the need for proton therapy in clinical scenarios for which proton therapy is not considered the standard of care. There is no documentation that a conventional three-dimensional (3D) conformal plan or intensity modulated radiation therapy (IMRT) would be unacceptable. All told, the requested proton beam radiation therapy is not 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 services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 61-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees colorectal cancer with liver metastases. The physician reviewer found that there is no medical literature to suggest that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for rectal cancer (Allen, et al). There is no data submitted that suggests that treatment with proton techniques will be able to improve sparing of the small bowel compared to standard intensity modulated radiation or three-dimensional (3D) conformal techniques with photons. The National Comprehensive Cancer Network (NCCN) guidelines do not support the use of proton therapy in this clinical setting. In the majority of cases, treatment with photon techniques is advised, especially in the palliative setting. Moreover, there is a lack of level I evidence to support the use of proton therapy for the treatment of rectal cancer. Based on these reasons, the requested proton beam therapy is not 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 services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 61-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees colorectal cancer with liver metastases. The physician reviewer found that the potential benefit of proton therapy over photon therapy lies in its potential ability to spare normal tissue adjacent to the treatment volume. While proton therapy appears superior to photon therapy dosimetrically, it does not always translate into a clinical benefit. There is a paucity of randomized or retrospective trials supporting proton therapy in the treatment of rectal cancer. The lack of studies for proton cancer in rectal cancer is likely due to the fact that proton therapy excels in clinical scenarios where there is a sharp border between the radiation target and normal tissue, especially if it occurs in a tight space. This is not the clinical scenario for rectal cancer. The treatment volume for rectal cancer is relatively large, and includes the entire rectum and the mesorectum. The main acute side effect of radiotherapy for rectal cancer is diarrhea, and is due to the fact the entire rectum receives the full dose of radiation. Because the rectum is the target of radiotherapy, it is not possible nor desirable to spare the rectum from radiation. The other structures that may be of concern in sparing for rectal radiation are the small bowel and bladder. Given that the dose tolerance for the small bowel is 50 Gy, and that the dose required in a palliative setting should be below 50 Gy, there is no perceived benefit to proton therapy in sparing the small bowel from a dose below tolerance. Moreover, proton therapy is not recommended in the National Comprehensive Cancer Network (NCCN) guidelines for rectal cancer. For these reasons, the requested proton beam radiation therapy is not 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 services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 60-year-old female enrollee has requested authorization and coverage for stereotactic body radiotherapy. 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 fails to demonstrate the medical necessity of the requested services. This patient has progression of her breast cancer following standard chemotherapy. Standard treatment in this setting is with second-line chemotherapy and palliative radiation to her spine for pain. There are cases when patients with certain histologies (colorectal, lung and breast) with limited metastatic disease who are eligible for stereotactic body radiotherapy. However, this patient does not have oligometastatic disease, as she had widespread metastases at the time of presentation. There is a lack of convincing medical evidence that suggests that patients with widespread breast cancer benefit from stereotactic body radiotherapy for spine metastases. Therefore, stereotactic body radiotherapy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 32-year-old male enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees central nervous system (CNS) germinoma. The physician reviewer found that IMRT is a tool that providers can use when there is concern about sparing normal tissues from high dose exposure. IMRT generally implies inverse planning algorithms to maximize dose to the target and minimize dose to normal tissues. In the medical literature, Sakanaka and colleagues evaluated IMRT for CNS germinoma. The authors found that IMRT demonstrated better conformality in target coverage and better sparing of normal brain with IMRT in the treatment of CNS germinoma than 3D conformal radiation therapy. For CNS germinoma, the prescribed dose is relatively low and still below the accepted tolerance of the brainstem, optic nerves, retina and below the risk for brain necrosis. However, the target is complex in shape and IMRT would be more conformal in this clinical setting. For these reasons, the requested IMRT for this case is an accepted standard and supported as medically necessary for treatment of this patients CNS germinoma. In sum, 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 17-year-old male enrollee has requested reimbursement for residential treatment center (RTC) services provided from 4/4/15 through 6/10/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees major depressive disorder, recurrent. The physician reviewer found that the submitted records from 4/4/15 through 6/10/15 fail to support the need for RTC level of care for treatment of this patients medical condition. The notes that were submitted contain little or no information about the patients behaviors or mental status. In addition, there is no documentation of any problem behaviors or medical problems. The patients history explained his lack of cooperation with therapy prior to admission. However, there was no stated reason for continuation of treatment as of 4/4/15. All told, the RTC services provided from 4/4/15 through 6/10/15 were not medically necessary for treatment of this patients behavioral health issues. Based on the foregoing discussion, 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 

A 45-year-old male enrollee has requested reimbursement for air ambulance transport provided on 12/17/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that it is in the best interest of patient safety to transfer to the nearest appropriate facility that has the ability to best care for the injury or illness. Transfers are inherently fraught with risk, and air transfers in particular carry their own set of additional complicating factors. The determination of what is the most appropriate facility can be very complex and involves many factors, only one of which is proximity to the sending facility.  It is best left in the hands of the clinical team with hands on the patient at the time a facility is to be selected to determine what his or her needs are and, therefore, what the most appropriate facility is. This based on services, availability in the moment, proximity, reachability, family/social network, and many other factors that are only possible to determine in real time. In this patients case, ground transportation or commercial air travel were not appropriate options. The medical evidence supports the services at issue in this clinical setting. Therefore, air ambulance transport provided on 12/17/18 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 57-year-old male enrollee has requested reimbursement for Oncotype DX testing Prostate Cancer Assay provided on 9/15/15. The Health Plan has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees elevated prostate specific antigen (PSA). The physician reviewer found THE testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the testing at issue in this clinical setting. Several tissue-based molecular assays have been developed in an effort to improve decision-making in newly diagnosed patients considering active surveillance and in treated men considering adjuvant therapy or treatment for recurrence. Patients with clinically localized disease may consider the use of tumor-based molecular assays. Retrospective case cohort studies have shown that molecular assays performed on biopsy or 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. In this case, the patient has low-risk localized prostate cancer and the testing at issue was indicated to assist with improve decision-making. All told, the Oncotype DX testing provided on 9/15/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 57-year-old male enrollee has requested reimbursement for Oncotype DX testing Prostate Cancer Assay provided on 9/15/15. The Health Plan has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees elevated prostate specific antigen (PSA). The physician reviewer found that the gene expression analysis, such as Oncotype DX utilized to guide management of prostate cancer remains controversial at this time. Oncotype DX testing has not been validated with prospective randomized clinical trials. There is a lack of evidence from well conducted prospective clinical trials demonstrating that the utilization of Oncotype DX has an impact on patient health outcome. Therefore, the Oncotype DX testing provided on 9/15/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 57-year-old male enrollee has requested reimbursement for Oncotype DX testing Prostate Cancer Assay provided on 9/15/15. The Health Plan has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees elevated prostate specific antigen (PSA).The physician reviewer found that once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features such as the grade of tumor and PSA level. This helps guide the most appropriate therapy for patients taking into account their age and co-morbidities because many patients will not require therapy surgery or radiation and may be followed closely instead. The important features to recognize are Gleason score and PSA but these are imperfect. Thus, current biomarkers are inadequate for risk stratification and better prognostic biomarkers are needed. The Prostate Oncotype DX is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score (GPS). A validation study was presented at the American Urological Association meeting in 2013 involving 395 patients (Cooperberg, et al; Eastman; Knezevic, et al). The GPS identified patients that had very low risk disease that could be followed rather than referred for surgery. In addition, the National Comprehensive Cancer Network (NCCN) guidelines suggest the Oncotype DX test to better stratify such patients with localized disease. For the reasons provided, the Oncotype DX testing provided on 9/15/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 52-year-old male enrollee has requested authorization and coverage for Vascepa. 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 supports the medical necessity of the requested medication. This patient has established coronary artery disease and is at significantly higher cardiovascular event risk at his age due to his elevated calcium score. He has been maximized previously for his hyperlipidemia and hypertriglyceridemia with diet, high dose statin medication and Lovaza, with marked improvement in his lipid profile. Although eicosapentaenoic acids have been shown to possibly have effects on cardiovascular risk previously, the most recent data specifically on the preparation Lovaza, while effective at lowering triglyceride level, has not been shown to affect cardiovascular risk or freedom from cardiovascular events in the recent ASCEND trial. Most recently, the specific icosapent ethyl preparation, Vascepa, has been shown to lower both triglyceride levels and decrease cardiovascular events in high risk patients with either known coronary artery disease or diabetes mellitus. Given that this patient is already on triglyceride lowering therapy and has known established coronary artery disease, it is appropriate that he be on lipid lowering therapy that has been clinically shown to decrease his cardiovascular risk. Vascepa is medically indicated in this specific, high-risk clinical circumstance. Therefore, Vascepa is medically necessary for the treatment of this patient.