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

Summary Reviewer 2


The parent of a six-year-old male enrollee has requested authorization and coverage for Saizen 8.8 mg click easy cartridge.  The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition The physician reviewer found this patient was born small for gestational age and has failed to catch up in weight and length since birth. He has low growth factors and a small pituitary gland as well. Per the medical evidence, sustained postnatal growth failure in children who have been small for gestational age is considered an indication for growth hormone treatment in children. Provocative growth hormone testing is not required for diagnosis and treatment for this indication.  Therefore, the requested Saizen 8.8 mg click easy cartridge is likely to be more effective than other treatment options.  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 parent of a six-year-old male enrollee has requested authorization and coverage for Saizen 8.8 mg click easy cartridge.  The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition The physician reviewer found growth hormone therapy is indicated for the treatment of growth failure in children born small for gestational age who fail to manifest catch-up growth by two to four years of age.  Most infants who are small for gestational age have sufficient postnatal catch-up growth to normalize their stature by two years of age.  Growth hormone therapy is a recognized therapy for children who are born small for gestational age, but who fail to have catch-up growth.  Thus, Saizen 8.8 mg click easy cartridge is likely to be more efficacious than other treatment options.  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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 32-year-old male enrollee has requested authorization and coverage for RT300 therapy system. The Health Insurer has denied this request and reported that the requested device is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that Locked-in syndrome is a very rare condition characterized by paralysis of almost all muscles that are under voluntary control (except, classically, for the muscles responsible for vertical eye movements), while consciousness and cognition remain intact. The condition is often mistaken for a vegetative state. In this case, the patient had bilateral brainstem strokes in 2011, which is the typical etiology responsible for a locked-in state. As of May 2016, he had recovered to a level where he had essentially normal left upper limb strength. He had weak but functional right upper limb strength. He was able to perform some functional tasks with assistance. He was mute/aphonic, but communicating with the assistance of an application on his mobile phone.  The patients most recently described functional status in the available documentation is not compatible with persistent locked-in syndrome. An upper body functional electrical stimulation cycle ergometer has been recommended for the patient. There is no indication, however, that the patient could not use a standard upper body cycle ergometer for exercise, i.e., without the functional electrical stimulation component. There is some weakness in the right upper limb, but left upper limb strength is essentially intact. There is a lack of published data that establish a benefit of use of the device in question for the patients condition. It is not a proven adjunct or substitute for active exercise using volitionally intact muscles in the setting of this patients condition. It is not reasonably expected to improve function, health or incidence of complications. Therefore, the requested RT300 therapy system is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 38-year-old male enrollee has requested authorization and coverage for neck surgery.  The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition.  The physician reviewer found that the requested services are not likely to be more effective for this patient than other available options. Based on the documentation submitted for review, the patient has left C6 radiculopathy with matching motor and sensory symptoms and findings. Thus, there is disc herniation at C5-6. However, the use of Mobi-C remains controversial.  There is a lack of studies demonstrating the long term safety and effectiveness of this device. There are is a lack of controlled, prospective studies that have reported the long term safety and effectiveness of this device. According to Zechmeister and colleagues 
cervical total disc replacement (CTDR) is not recommended for routine use. The authors further state that Future research needs to address the relative effectiveness between CTDR and conservative treatment. All told, the requested neck surgery 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 38-year-old male enrollee has requested authorization and coverage for neck surgery.  The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition.  The physician reviewer found that the requested cervical disc replacement at C5-6 with Mobi-C total disc replacement is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The proposed surgery, especially for single-level cervical is likely to be more beneficial than other treatment options. Moreover, the study by Jackson and colleagues found that treatment with cervical total disc replacement results in a significantly lower rate of subsequent surgical intervention than treatment with anterior cervical discectomy and fusion for both 1 and 2 levels of treatment. For the reasons provided, the requested neck surgery 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 services are 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 Upheld

Summary Reviewer 3

A 38-year-old male enrollee has requested authorization and coverage for neck surgery.  The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition.  The physician reviewer found that there is insufficient data in the medical literature to adequately assess the performance of total disc replacement. There is a lack of evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. Total disc replacement has been associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been fully documented. Additionally, total disc arthroplasty has been associated with substantial morbidity. In this clinical setting, the gold standard procedure would be a single level anterior cervical discectomy and fusion. In sum, the requested services are 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 61-year-old female enrollee has requested authorization and coverage for a series of left knee Synvisc One injections. The Health Plan has denied this request and reported that the requested services are not medically necessary for treatment of the enrollees osteoarthritis.  The physician reviewer found that current evidence-based guidelines recommend hyaluronic acid injections in the knee as a possible option for patients with osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. Guidelines support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Guidelines state that there is no maximum amount of injections established by high quality scientific evidence, nor is one type of viscosupplementation supported over another. This patient presents with chronic left knee pain with intermittent swelling, grinding, and instability. She is status post ACL reconstruction. She reports functional difficulty interfering with her work ability. She had failed reasonable conservative treatment, including medications, corticosteroid injections and physical therapy. Criteria have been met for the use of viscosupplementation for this patients medical condition. However, current evidence-based guidelines and peer-reviewed literature indicate that there is a general lack of reliable evidence that any specific brand is superior to others. There is no compelling rationale presented to support the medical necessity of Synvisc One as the initial viscosupplementation agent. Therefore, the requested series of left knee Synvisc One injections is not medically necessary for the treatment of this patient. Therefore, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1
A 63-year-old female enrollee has requested reimbursement for laboratory testing (collagen crosslink testing) performed on 2/25/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of osteoporosis.  The physician reviewer found that osteoporosis is a condition of thinning of the bones which leads to increased risk of fracture. It  is defined by the World Health Organization (WHO) as a bone mineral density of 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults) as measured by dual-energy x-ray absorptiometry (DEXA). Bone mineral density (BMD) assessment, via DEXA, is still the criterion standard for evaluation and diagnosis of osteoporosis.  However, because changes in bone mass and density in response to antiresorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover may be a useful adjunct in monitoring of osteoporotic patients treated with antiresorptive agents. The medical evidence suggests that biochemical markers could be useful in making therapeutic decisions because, in general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine. There is sufficient support for the services at issue in this clinical setting. All told, laboratory testing (collagen crosslink testing) performed on 2/25/17 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 2

A 63-year-old female enrollee has requested reimbursement for laboratory testing (collagen crosslink testing) performed on 2/25/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of osteoporosis.  The physician reviewer found that markers of bone turnover, such as the collagen crosslinks, have been recognized by experts in osteoporosis as a tool to evaluate osteoporosis from diagnostic and therapeutic standpoints. There are multiple articles that show the value of this test with anabolic agents, such as Forteo. Antiresorptive agents decrease and anabolic agents increase the markers of bone turnover. These markers are useful to determine adherence and efficacy of therapy. Collagen crosslinks are also important in the diagnostic evaluation of osteoporosis that has failed to respond to treatment. This patient has received antiresorptive therapy in the past, so it was important to obtain markers of bone turnover. This testing allows the provider to assess the effectiveness of therapy and patient compliance. In this patients case, the services at issue were an important component of monitoring therapy.  In sum, laboratory testing (collagen crosslink testing) performed on 2/25/17 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 Overturned

Summary Reviewer 3

A 63-year-old female enrollee has requested reimbursement for laboratory testing (collagen crosslink testing) performed on 2/25/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of osteoporosis.  The physician reviewer found that the current medical evidence has not established the superior efficacy of the services at issue. The value of monitoring therapy with the use of biochemical markers of bone turnover to aid in clinical decision is controversial. This testing can be variable and subject to timing and dietary intake. Additionally, there is a lack of assay standardization. Thus, laboratory testing (collagen crosslink testing) performed on 2/25/17 was not 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 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 

The patient is a 16-month-old male who was born by Cesarean section at 32 weeks 3 days gestation. The patients parent has requested reimbursement for physical therapy and speech therapy services provided from 7/22/20 through 8/24/20. 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 This patient was born prematurely, at 32 weeks 3 days gestation. He spent four weeks in the NICU, and required a feeding tube. He has documented developmental delays, including gross motor delays, apraxia, poor emotional regulation, and feeding difficulties. Spittle and colleagues noted, Infants born preterm are at increased risk of developing cognitive and motor impairment compared with infants born at term. Early developmental interventions have been provided in the clinical setting with the aim of improving overall functional outcomes for these infants." Woodward and colleagues reported that infants born before 34 weeks of gestation have three times the risk of impairments in multiple developmental domains compared with term infants. Bui and colleagues stated, Preterm children should be screened regularly for developmental delay, and parents of preterm infants should be counseled about the options of early intervention programs, and their potential positive impact on development. The medical evidence supports the services at issue in this clinical setting. Therefore, physical therapy and speech therapy services provided from 7/22/20 through 8/24/20 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 44-year-old male enrollee has requested reimbursement for DecisionDX-Melanoma assay rendered on 2/1/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees malignant melanoma. The physician reviewer found that the medical research indicates that melanoma is a cancer that is curable in its earliest stages. There is very little data on the DecisionDX test for melanoma. 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 they suggest a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. Castle Biosciences which developed and markets the test states that it has been validated prospectively. These data are not published and not available for review. As such, this test is very novel and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. This was also the consensus opinion of the National Comprehensive Cancer Network guidelines. In sum, DecisionDX-Melanoma assay rendered on 2/1/16 was not medically necessary for the evaluation of this patients cancer. Therefore, based on the stated reasons above, the services at issue were not medically necessary for evaluation of the patient. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 53-year-old female enrollee has requested reimbursement for the homocysteine testing performed on 3/9/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees peripheral neuropathy. The physician reviewer found that this patient presented with a focal peripheral nerve symptom in the distribution of the right superficial peroneal nerve with no sensory findings on exam, normal EMG, and mild changes on MRI. Overall, the patients history and findings do not support a diagnosis of peripheral neuropathy, and the laboratory testing performed would not be expected to show any related abnormalities. Homocysteine levels are checked when a patients B12 and/or methylmalonic acid levels are equivocal. However, routine use of methylmalonic acid and homocysteine is not considered the standard of care for the work-up of peripheral neuropathy, as methylmalonic acid is the usual confirmatory test and homocysteine is generally not helpful. As B12 deficiency can be diagnosed with standard testing with use of B12 and methylmalonic acid, and homocysteine is obtained if initial testing is equivocal, the homocysteine testing performed on 3/9/16 was not more likely to lead to a proper diagnosis over standard testing. 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 Upheld

Summary Reviewer 2


A 53-year-old female enrollee has requested reimbursement for the homocysteine testing performed on 3/9/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees peripheral neuropathy. The physician reviewer found that Homocysteine level testing is supported in cases of anemia and bleeding disorders. This testing may also be used to characterize etiology of B12 deficiency. However, homocysteine level testing lacks data supporting its utility as a standard test in the evaluation of peripheral neuropathy. Wile and Toth noted that homocysteine testing is not supported in routine testing for peripheral neuropathy but may be used in diabetic neuropathy. All told, the homocysteine testing performed on 3/9/16 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 Upheld

Summary Reviewer 3


A 53-year-old female enrollee has requested reimbursement for the homocysteine testing performed on 3/9/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees peripheral neuropathy. The physician reviewer found that there is support for testing patients with distal sensory symptoms without a clear etiology for treatable causes of a length-dependent peripheral neuropathy. One such cause relates to elevated homocysteine levels. If detected, this can be treated with B12 even in the context of normal B12 levels. Thus, although there is limited data demonstrating improved health outcomes with homocysteine testing in this clinical setting, some literature has linked homocysteine levels to treatable cases of neuropathy. Accordingly, the homocysteine testing performed on 3/9/16 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.