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

Summary Reviewer 


A 31-year-old male enrollee has requested authorization and coverage for anastrozole 1 mg. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient is being treated for testicular hypodysfunction with testosterone and human chorionic gonadotropin.  The laboratory studies from November 2015 and February 2016 show normal or high values of testosterone.  For men who are hypogonadal, as evidenced by clinical symptoms and signs consistent with androgen deficiency and a subnormal morning serum testosterone concentration on three separate occasions, testosterone replacement therapy is recommended. The approved uses for anastrozole 1 mg include first-line treatment of locally-advanced or metastatic breast cancer (hormone receptor-positive or unknown) in postmenopausal women, adjuvant treatment of early hormone receptor-positive breast cancer in postmenopausal women or treatment of advanced breast cancer in postmenopausal women with disease progression following tamoxifen therapy.  In this case, the patient does not have an approved indication for the use of anastrozole.  Furthermore, this medication is not recommended for the use of testicular hypofunction.  The documentation supports that the patient has had improved symptoms while taking testosterone and human chorionic gonadotropin.  Thus, the requested anastrozole 1 mg is not medically indicated for the treatment of this patient.  Therefore, the requested medication is 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 69-year-old male who has requested reimbursement for targeted genomic sequence analysis with Foundation One performed in January 2020. He was diagnosed with a stage IIIA melanoma of the right chest wall in 2014.  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines recommend that patients with metastatic melanoma have broader genomic profiling if feasible, especially if the test results might guide future treatment decisions or eligibility for participation in a clinical trial. If BRAF single-gene testing is the initial test performed, and is negative (as in this patient), clinicians should strongly consider larger next generation sequencing panels to identify other potential genetic targets. Consideration of broader genomic profiling is recommended if the test results might guide future treatment decisions or eligibility for participation in a clinical trial. There is sufficient support for the services at issue in this clinical setting. Therefore, targeted genomic sequence analysis performed on 1/24/20 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 50-year-old female who presented to the hospital on 5/04/21 with a generalized weakness starting approximately one month earlier, but worsening in the last four days. The patient has requested authorization and coverage for acute rehabilitation admission. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that Ethanol is a neurotoxin known to cause cerebral and cerebellar pathology, resulting in cognitive dysfunction, gait ataxia, loss of manual dexterity, and a generalized accelerated functional decline relative to normative expectations for age. The gait problems associated with chronic alcoholic use are generally progressive, and not expected to improve spontaneously through neurological recovery. Rehabilitation measures in the setting of acute on chronic functional disorders with impaired gait and impaired safety awareness, etc., such as in this current clinical setting, can include further medical optimization, endurance building, devising and promoting compensatory strategies, safety promotion, family/caregiver training and finding/fostering a supportive/appropriate residential environment. There is no need, however, for these services to be provided in an acute inpatient rehabilitation facility. There is no proven marginal benefit of high intensity services for this type of rehabilitation over rehabilitation provided in a less intensive setting. The rehabilitation and convalescence related to this condition is a protracted process. Notably, despite the therapy the patient has been undergoing in the facility, her functional gains have been minimal. Intensifying the services is not expected to positively impact her recovery course or outcomes. Therefore, acute rehabilitation admission is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 31-year-old female enrollee has requested reimbursement for residential substance abuse treatment services provided from 6/16/14 through 8/16/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse. The physician reviewer found that The records indicate that this patients last use of alcohol was 10 days prior to admission and did not require detoxification. She had no post-acute withdrawal symptoms, she was not a danger to herself or others, and had no self-harm urges. She was medically stable as her Crohns disease did not require management in the residential setting. Her psychiatric medications were unchanged during the course of her stay. She presented as motivated and insightful, aware that she needed help maintaining sobriety and having the desire to gain insight. She had two prior periods of prolonged abstinence, demonstrating the ability to remain sober in an unstructured environment. She had prior residential treatment and exposure to AA, thereby having a degree knowledge of relapse prevention and sober supports in the community. Moreover, her environment was supportive. The patient could have adequate and effective treatment on an ambulatory level such as partial hospitalization program (PHP) or intensive outpatient program (IOP), and did not require residential level of care. Thus, the residential substance abuse treatment services provided from 6/16/14 through 8/16/14 were not medically necessary for treatment of this patients substance use disorder. 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 

The patient is a 43-year-old male with a history of bilateral squamous cell carcinoma of his oropharynx, cT3N0M0 stage II left tonsillar cancer and cT1N0M0 stage I right tonsillar cancer. The patient has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. It is appropriate to spare the more superficial parotid gland, while maintaining coverage of the deep parotid/level II nodal region, as the treating provider has demonstrated in the plan comparison. The provider has shown that the use of photon-based intensity modulated radiation therapy would be associated with an excessive risk for parotid gland injury, resulting in xerostomia that would put the patient at an unacceptable risk for complications, such as swallowing dysfunction and dental caries. The proton radiation plan was able to significantly reduce the parotid exposure to within known safe tolerance limits, thereby minimizing this risk for high-grade radiation-induced morbidity. Proton radiation is supported by the American Society for Radiation Oncology (ASTRO) Model Policy and National Comprehensive Cancer Network guidelines in this setting, as the provider has shown that photon-based radiotherapy cannot be delivered with adequate safety/precision. Therefore, the requested proton beam radiation therapy is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 50-year-old female enrollee has requested authorization and coverage for Harvoni and ribavirin. The Health Insurer has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 3a. The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni and weight based ribavirin for 12 weeks. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested treatment with Harvoni and ribavirin is supported as medically necessary for treatment of this patients hepatitis C virus infection. All told, the requested medications 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 


A 37-year-old male enrollee has requested authorization and coverage for Afinitor 5 mg one tablet daily. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees anaplastic ependymoma. The physician reviewer found that the records provided for review document that this is a patient with refractory ependymoma. The treating provider has recommended treatment with Afinitor. However, there is a lack of peer-reviewed medical literature supporting the effectiveness of Afinitor in this clinical setting. The available data on the use of Afinitor in patients with ependymoma is not single agent use data. In addition, the available reports are phase 1 data. Moreover, the National Comprehensive Cancer Network (NCCN) guidelines do not include Afinitor as an active agent in the treatment of ependymoma. All told, Afinitor may subject a patient to significant toxicities, which suggests its use should not be performed outside of a clinical trial.  Accordingly, the requested Afinitor 5 mg, one tablet daily, is not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested medication is 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 55-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/02/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that there is sufficient support for the service at issue in this clinical setting. Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with very dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional mammographic protocol was likely of greater benefit to the patient than had her mammogram been done with two-dimensional imaging alone.  Based upon the information set forth above, the service 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 55-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/02/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that 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.  In this patients case, her breast tissue was described as extremely dense.  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 sum, digital breast tomosynthesis performed on 9/02/16 was likely to have been more effective than other modalities for evaluating this patient.  Based upon the information set forth above, the service 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 3


A 55-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/02/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that the current medical evidence supports the service at issue in this patients case.  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 noted integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Thus, digital breast tomosynthesis performed on 9/02/16 was likely to have been more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the service 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 Upheld

Summary Reviewer 

A 38-year-old male enrollee has requested authorization and coverage for Praluent 75 mg/mL pen, 75 mg injected subcutaneously once every two weeks. 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 fails to demonstrate the medical necessity of the requested medication. In this patients case, there is no documented clinical cardiovascular disease. He has mild hyperlipidemia while on pravastatin and ezetimibe. In this circumstance, treatment with a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor is not medically necessary.  Praluent is a PCSK9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient does not fit any of those criteria.  There is no documentation to support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia. PCSK9 inhibitors have not been studied in other patient populations. The current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Therefore, Praluent 75 mg/mL pen is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 42-year-old male enrollee has requested reimbursement for magnetic resonance imaging (MRI) of the brain and cervical spine performed on 9/04/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees multiple sclerosis. The physician reviewer found that although no definite current imaging guidelines are available for imaging in multiple sclerosis, the following recommendations are based on current literature and clinical practice. If multiple sclerosis is suspected, MRI of the brain with and without contrast as well as cervical and thoracic spinal cord is indicated as a baseline examination. If a diagnosis of multiple sclerosis is made, then follow-up imaging of the brain and possibly spinal cord (depending on initial imaging results) is recommended three to six months after starting disease modifying treatment. If the diagnosis is unclear and thought to be a clinically isolated syndrome, not definitively multiple sclerosis, then the patient can be imaged with MRI of the brain and possibly spinal cord in one to three months, also depending on if the spinal cord was initially affected. Imaging thereafter is then approximately every six to 12 months. In this case, the patient had initial brain and cervical/thoracic imaging in April 2018 and May 2018, respectively. As the initial spinal imaging was negative, follow-up spinal imaging was not medically necessary four months later, on 9/04/18. Per the medical evidence, follow-up MRI of the brain on 9/04/18 was medically necessary. In sum, MRI of the brain was medically necessary for the evaluation of this patient. The records fail to demonstrate the medical necessity of MRI of the cervical spine. Therefore, a portion of the services at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 17-year-old male enrollee has requested reimbursement for repair of nasal vestibular stenosis performed on 8/10/18. 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 this patient had an acquired nasal deformity and obstruction of nasal breathing. He underwent functional rhinoplasty to restore nasal breathing. Internal valve collapse can lead to nasal obstruction. It is characterized by the collapse during inspiration of the upper lateral cartilages. A narrowing of the angle between the dorsal septum and upper laterals can also contribute, but to a lesser extent. Placement of precise cartilage grafts have been demonstrated to provide support which improves nasal breathing. This patient had internal valve collapse with improvement with the modified Cottle maneuver. Repair of vestibular stenosis was medically indicated in this setting. The photographs clearly document collapse of the upper lateral cartilage. The medical evidence supports the services at issue in this clinical setting. Therefore, repair of nasal vestibular stenosis performed on 8/10/18 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 61-year-old male enrollee has requested authorization and coverage for Tykerb. 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 there is a lack of support for the requested medication in this patients case. In the setting of metastatic breast cancer to brain, there has been interest in using Tykerb because of its purported better entry into the central nervous system. In the setting of breast cancer, there may be some advantage with combining Tykerb with chemotherapy such as Xeloda. However, the benefit of Tykerb alone is not established. Additionally, one cannot necessarily analogize treatment of salivary gland cancer with that of breast cancer. Therefore, Tykerb is not likely to be more efficacious than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 61-year-old male enrollee has requested authorization and coverage for Tykerb. 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 salivaray gland tumors are rare. HER2 is expressed in about one-third of salivary gland tumors. Tykerb (lapatinib) is an orally active dual inhibitor of EGFR and HER2. Agulnik and colleagues studied this medication in a phase II trial of 40 patients. Although no responses were observed, 47 percent of patients treated with lapatinib had prolonged tumor stabilization of at least six months. Since disease progression prior to enrollment was required in this trial, the prolonged tumor stabilization may be more likely due to true drug effect. The medical evidence supports the requested medication in this patients case. In sum, Tykerb is likely to be of greater benefit than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 61-year-old male enrollee has requested authorization and coverage for Tykerb. 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 this patient has a salivary gland cancer, which is a rare tumor that has a high propensity for distant metastases.  Stage IV disease, as in this case, is very difficult to treat because it is poorly responsive to conventional chemotherapy regimens. Since the tumor is rare, large randomized clinical trial evidence cannot be expected. Patients with refractory or relapsed cancer who have exhausted standard treatments are usually considered for clinical trials. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Von Hoff and colleagues performed a study of 86 patients where the progression-free survival on regimen selected by molecular profiling was compared to progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This patient was treated with paclitaxel and trastuzumab along with directed stereotactic radiotherapy of the brain metastases. The records documented disease progression, and his provider is attempting to target the HER2 amplification by lapatinib. There is phase II data demonstrating that this drug may induce stable disease in patients with salivary gland cancers. It also penetrates the blood-brain barrier and may be more effective than trastuzumab. Thus, Tykerb is likely to be more effective than other available treatment options.