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

Summary Reviewer 3

The patient is a 61-year-old female who has been diagnosed with attention deficit hyperactivity disorder (ADHD), malabsorption syndrome, and history of binge eating disorder. She is status post Roux-en-Y gastric bypass. On 2/2/17, the patient reported that Vyvanse lasts for four hours, there are no side effects, and the patients sleep is good. She finds taking it three times a day is effective. The provider indicated that she has been stable on this dose since 9/3/12, and needs this to continue as she works 12-14 hours a day. The Vyvanse 70 mg three times a day maintains her focus, concentration, and energy, and helps control erratic eating. The patient has requested authorization and coverage for Vyvanse 70 mg three times a day (TID). The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational. 
The records indicate that this patient has a history of ADHD, history of binge eating disorder, and is status post Roux-en-Y gastric bypass with malabsorption syndrome. As noted in the medical literature, malabsorption syndromes can occur in all gastric bypass procedures and can require patients to take higher doses than normal to achieve the desired effect. This patient has reported no side effects with continued efficacy. For these reasons, Vyvanse 70 mg TID is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. 
Based upon the information set forth above, the requested medication dosage 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 Overturned

Summary Reviewer 


The parent of a 10-year-old female enrollee has requested authorization and coverage for Nutropin growth hormone (GH) therapy. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees short stature and ulcerative colitis.   The physician reviewer found that the records provided for review demonstrate that this patient has extreme short stature with an adult height prediction that is less than 59 inches, which is short enough to meet U.S. Food and Drug Administration (FDA) criteria for a trial of GH therapy for idiopathic short stature. Although some of the patients growth failure may be attributed to underlying ulcerative colitis, poor nutritional intake, and poor weight gain, her ulcerative colitis is currently inactive, she is not receiving steroid medications that can impair growth, and her weight for her height is appropriate. Her normal ESR, iron studies, and complete blood count are evidence that her underlying ulcerative colitis is under control, yet she continues to have a poor growth velocity and has a very short adult height prediction. According to Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDs below the mean for age or more than two SDs below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient meets most of these criteria. Thus, GH therapy is indicated to improve her height potential. Accordingly, the requested Nutropin GH therapy is supported as medically necessary for treatment of this patients short stature. Based on these findings, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 53-year-old female enrollee has requested reimbursement for gene testing performed on 7/5/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees bilateral thyroid nodules. The physician reviewer found that while a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate (Alexander, et al). Until recently, the only method to establish whether the nodule was thyroid cancer was via surgical excision even though the majority of the cases are benign (Miller, et al). The Afirma Thyroid FNA Analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures (Duick, et al). Therefore, gene testing performed on 7/5/16 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.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 53-year-old female enrollee has requested reimbursement for gene testing performed on 7/5/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees bilateral thyroid nodules. The physician reviewer found that there is sufficient support for the Afirma gene test performed on 7/5/16 in this clinical setting. This patients biopsy was suspicious for follicular lesion of undetermined significance. The Afirma testing was suspicious, and a determining factor in delineating the further course of action to assess whether a surgical procedure was warranted. Afirma testing is considered standard protocol on fine needle aspirations performed on thyroid nodules. In sum, the testing at issue 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 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 53-year-old female enrollee has requested reimbursement for gene testing performed on 7/5/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees bilateral thyroid nodules. The physician reviewer found that the gene testing performed on 7/5/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the patient presented with bilateral thyroid nodules. The dominant nodule on the lower right lobe measuring 1.6 cm in largest diameter showed suspicious features in the thyroid ultrasound. The cytopathology of the 1.6 cm thyroid nodule was consistent with follicular neoplasm. The other nodule showed benign cytopathology. The American Thyroid Associations guidelines state that for follicular neoplasm nodules, molecular testing may be used to supplement malignancy risk assessment data in lieu of proceeding directly with surgery. Informed patient preference and feasibility should be considered in clinical decision-making (Haugen, et al). If the genetic test is suspicious, the risk of malignancy increases to 40% (Haugen, et al; Alexander, et al). However, the risk of malignancy decreases to less than 6% with benign findings by genetic testing (Haugen, et al; Alexander, et al). The test is therefore beneficial for the medical decision making. In this case, the result of the gene expression classifier was suspicious for malignancy. This result was helpful to direct subsequent management and a hemithythyroidectomy was recommended. All told, genetic testing was appropriate, in line with current specialty standards and 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 Upheld

Summary Reviewer 


A 28-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation and autologous cultured chondrocytes implant for left knee. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees left knee pain. The physician reviewer found that treatment of osteochondral defects with autologous chondrocyte implantation has been proposed for treatment of this patients cartilage defects in the knee. However, the current peer-reviewed medical literature provides limited support of this procedure in this clinical setting. The study by Andriolo and colleagues demonstrated additional studies are required. Similarly, Mistry and colleagues concluded that research is needed to fully assess the long-term results of autologous chondrocyte implantation. Given the absence of data supporting improved patient health outcomes with the requested procedure, autologous chondrocyte implantation and autologous cultured chondrocytes implant for left knee are not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested procedure 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 


A 63-year-old female enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found 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 should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). In addition, FibroSure has demonstrated high specificity when predicting advanced fibrosis, as in this case, although guidelines do not recommend restricting treatment based on fibrosis (Shaheen, et al). AASLD guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this patients hepatitis C infection. For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 54-year-old female enrollee has requested authorization and coverage for surgery to treat her heart rhythm. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee, who has a history of paroxysmal (AF) atrial fibrillation. The physician reviewer found that based on the records provided, this patient had atrial fibrillation that converted to normal sinus rhythm after treatment with Multaq followed by repeat cardioversion. There is a lack of documented recurrent atrial fibrillation since that time based on the records provided. Based on the records, atrial fibrillation ablation is not likely to benefit this patient. The patients symptoms persist but her nonspecific symptoms (malaise, fatigue) may not be due to atrial fibrillation. Current guidelines recommend consideration of atrial fibrillation ablation only if the patient has intolerance or recurrent atrial fibrillation in spite of at least one antiarrhythmic medication trial. In this patients case, the requested surgery to treat her heart rhythm is not likely to be more effective than the available standard therapy. Therefore, for the reasons stated 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 Overturned

Summary Reviewer 2


A 54-year-old female enrollee has requested authorization and coverage for surgery to treat her heart rhythm. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee, who has a history of paroxysmal (AF) atrial fibrillation. The physician reviewer found that this patient has a history of symptomatic paroxysmal atrial fibrillation. The records indicate that she has had several hospital stays from 2012 through 2016 with episodes of atrial fibrillation. She has tried two different antiarrhythmic agents. Rythmol, a class IC antiarrhythmic agent, was tried unsuccessfully in 2012. Most recently, in 2016, Multaq (dronedarone), a class III antiarrhythmic agent was also tried. The patient failed Multaq, having had a symptomatic recurrence of AF in August 2016. Based on current American Heart Association/American College of Cardiology/Heart Rhythm Society guidelines for patients with symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication which is paroxysmal, catheter ablation is recommended. This patients clinical situation meets accepted, guideline-directed indications for catheter ablation. As such, the requested surgery is likely to be more beneficial than standard therapies available to treat this patients heart rhythm. Therefore, for the reasons stated 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 Overturned

Summary Reviewer 3


A 54-year-old female enrollee has requested authorization and coverage for surgery to treat her heart rhythm. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee, who has a history of paroxysmal (AF) atrial fibrillation. The physician reviewer found that the patient has a history of persistent AF and has required cardioversions. She is now on antiarrhythmic drug therapy with dronedarone.  According to the guidelines endorsed by the American College of Cardiology, American Heart Association and the Heart Rhythm Society, catheter ablation of atrial fibrillation in this patient would be recommended, AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least one class I or III antiarrhythmic medication when a rhythm-control strategy is desired. In this patients case, the provider reported that the patient has symptomatic paroxysmal AF despite antiarrhythmic drug therapy. Thus, catheter ablation of atrial fibrillation was offered. In sum, the requested surgery to treat her heart rhythm is likely to be more effective than the standard options available for the treatment of this patients medical condition. Therefore, for the reasons stated 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 Overturned

Summary Reviewer 1

The parent of a four-year-old male enrollee has requested authorization and coverage for Botox 100 units. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that Botox injections have been successfully used for children with constipation due to Hirschsprung disease or anal achalasia. They are now being used in some centers for the management of refractory functional constipation. In this case, anorectal manometry has not yet been performed to assess for anal achalasia or non-relaxing internal anal sphincter, which, if present, would provide a clearer indication for Botox injection. Even in the absence of anal achalasia, refractory functional constipation which has not responded to medical therapy, and which otherwise would be treated with more invasive surgical procedures such as cecostomy, would support the use of Botox.  However, based on the clinical data provided, there was still some question as to whether senna would be an effective intervention, as well as whether milk of magnesia would be tolerated by the patient. There is also a mention of the use of enemas and suppositories in the past, but no indication as to why they could not be used more aggressively prior to moving forward with anal sphincter Botox injection. Therefore, in the absence of known anal achalasia, and in light of the possibility that other medical treatments might still be effective, the superior efficacy of the requested services over standard treatments has not been established. Therefore, J0585 - Botox 100 units are not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2
The parent of a four-year-old male enrollee has requested authorization and coverage for Botox 100 units. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. The records document cerebral palsy and constipation refractory to medical management. The patient has tried several medications and cleanouts, without success. This treatment is commonly used in motility centers for children with difficulty stooling due to problems relaxing the muscles. Studies have shown that it can be safe and effective for constipation that is difficult to treat. Therefore, J0585 - Botox 100 units are likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

The parent of a four-year-old male enrollee has requested authorization and coverage for Botox 100 units. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the use of Botox injection in treating refractory chronic constipation has been well-studied and supported by sufficient peer-reviewed literature. Keshtgar and colleagues performed a randomized clinical trial and noted that botulinum toxin is equally effective and less invasive than myectomy of the internal anal sphincter for chronic idiopathic constipation and fecal incontinence in children. 
Per Halleran and colleagues, Botox injection into the anal sphincters is an accepted practice in children with severe functional constipation. Studies have indicated that Botox is effective for children with chronic constipation and that injection may be considered in patients with intractable constipation unresponsive to medication, regardless of anal sphincter dynamics. The request for Botox injection in this case is consistent with the generally accepted practices. Therefore, J0585 - Botox 100 units are likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 26-year-old female enrollee has requested authorization and coverage for Xeljanz 5 mg The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees alopecia areata. The physician reviewer found that Alopecia areata is a chronic immunological disorder characterized by round or oval patches of non-scarring hair loss. Other autoimmune diseases are also linked with alopecia areata. Treatment is challenging and aims at the regrowth (reconstruction) of hair. Alopecia areata causes dramatic and devastating emotions in patients, which can negatively impact their self-esteem, body image, and self-confidence. Xeljanz (tofacitinib citrate) has been approved for the treatment of moderate to severe rheumatoid arthritis. It has been also studied for treatment of psoriasis, inflammatory bowel disease, and other immunological diseases. Several recent reports in the literature provide evidence for the effectiveness of this medication in the treatment of alopecia areata. Therefore, Xeljanz 5 mg is likely to be superior over 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 2

A 26-year-old female enrollee has requested authorization and coverage for Xeljanz 5 mg The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees alopecia areata. The physician reviewer found that Alopecia areata is autoimmune in nature and brings psychological manifestations as well as physical. The use of Xeljanz has shown some promise, with better results than any other available standard treatment, other than maybe long-term oral steroids, which are limited by their side effects. In this clinical setting, Xeljanz is likely to offer this patient the safest option to treat her ongoing disease. In sum, Xeljanz 5 mg are likely to be of greater benefit than other treatment modalities. 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.