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

Summary Reviewer 

A 59-year-old female enrollee has requested authorization and coverage for Alvesco 160 mcg inhaler, 1 puff twice per day for one year. 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 Alvesco (ciclesonide) has been approved by U.S. Food and Drug Administration for the treatment of persistent asthma. Ciclesonide is converted to an active metabolite desisobutyryl-ciclesonide in the lungs. The anti-inflammatory effect of desisobutyryl-ciclesonide is much higher than ciclesonide. Therefore, the local effect of the metabolite is higher, with lower systemic side effects. Ciclesonide has favorable pharmacokinetic and pharmacodynamic properties as inhaled corticosteroid, including low oral bioavailability, high plasma protein binding and rapid systemic clearance, high pulmonary deposition and distribution, and long pulmonary residence duration. These advantageous properties make ciclesonide an effective treatment option with low side effects.  The medical records indicate that this patient has tried another inhaled corticosteroid which was associated with increased symptoms of fatigue, and her symptoms were well maintained on ciclesonide. Therefore, it is medically appropriate to maintain the patient on the current ciclesonide to minimize side effects and improve asthma symptoms. Therefore, Alvesco 160 mcg inhaler, one puff twice per day for one year is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 59-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 9/06/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrolleei12s medical condition. The physician reviewer found that this patient had an early stage melanoma with low risk features. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. There is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy. Therefore, DecisionDx-Melanoma assay performed on 9/06/18 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 20-year-old female who has been diagnosed with posttraumatic stress disorder,
major depressive disorder, generalized anxiety disorder, and alcohol use disorder.The
patient has requested reimbursement for mental health residential treatment provided from 3/22/20
through 5/22/20. The Health Insurer has denied this request and reported that the services at issue
were not medically necessary for the treatment of this patient.The physician reviewer found the mental health residential
treatment provided from 3/22/20 through 5/22/20 was medically necessary for the treatment of this
patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The parent of a 15-year-old male enrollee has requested reimbursement for Afirma gene testing provided on 6/16/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found the review of the submitted documentation and relevant literature supports the testing at issue in this clinical setting. This patient presented with atypical cells in the first biopsy.  It was important to clarify his risk of harboring a malignancy when the second biopsy came back indeterminate again. Molecular testing has been proposed as an adjuvant in medical decision making of whether to refer a patient for thyroidectomy. According to the American Thyroid Association (ATA) guidelines For nodules with [atypia of undetermined significance/follicular lesion of undetermined significance] AUS/FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. In this case the repeat biopsy was again indeterminate. Therefore the submission of the specimen to Afirma gene expression classifier was appropriate. The result was suspicious which indicates that the risk of malignancy was 40%. A benign result would have prevented unnecessary surgery in this young patient. The rate of unnecessary surgeries has decreased with the use of molecular testing (Alexander, et al). In this case the decision to refer the biopsy specimen to Afirma testing was appropriate for the best care of this patient. Based on the support in the peer-reviewed literature, the Afirma gene testing provided on 6/16/15 was likely to be more beneficial for evaluation of the patients medical condition than other modalities. 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

The parent of a 15-year-old male enrollee has requested reimbursement for Afirma gene testing provided on 6/16/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found thyroid nodules are commonly managed by diagnostic fine needle aspiration to evaluate the cytopathology. In this case the finding by this standard technique was atypia of undetermined significance (Baloch, et al). This diagnostic category creates a dilemma with regards to recommended surgery. In this case, the patient was facing total thyroidectomy if malignancy was present and but only subtotal thyroidectomy if the lesion turned out to be benign. Hence, the sample was submitted for gene expression analysis. The Afirma gene expression test has demonstrated a very high negative predictive value for malignancy (Alexander, et al; Chudova, et al). In this case, the Afirma test performed was clinically indicated 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


The parent of a 15-year-old male enrollee has requested reimbursement for Afirma gene testing provided on 6/16/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found 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 way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign (Miller, et al). A relatively new test, 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). All told, 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 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 63-year-old female enrollee has requested authorization and coverage for Forteo. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees osteoporosis. The physician reviewer found that this patient has severe osteoporosis and multiple gastrointestinal issues. However, the medical records fail to demonstrate evidence of kidney disease or any pending dental issues or plans for major dental work.  She is reported to have small bowel dysmotility, celiac disease, and colonic inertia and unable to take oral bisphosphonates. There is no history of contraindication to bisphosphonates or chronic kidney disease. Given her history, the current guidelines would recommend intravenous bisphosphonates (zoledronic acid) as the preferred agent for this patient. Reclast or zoledronic acid is preferred if oral bisphosphonates cannot be tolerated. Prolia is a recommended alternative in this patients case. Reclast would be would be an option in this case given her normal renal function, Candidates for teriparatide include those with severe osteoporosis and are at high risk for fracture (T-score of -3.5 or below without fractures; T-score of -2.5 or below plus a fragility fracture), those who cannot tolerate bisphosphonates or who have relative contraindications to oral bisphosphonates (achalasia, scleroderma esophagus, esophageal strictures) and those who have failed other osteoporosis therapies. In this patients case, she does have evidence of severe osteoporosis and has reported that she cannot take oral bisphosphonates. However, the records do not show that she has tried other therapies like Reclast or Prolia.  As such, Forteo is not medically necessary for treatment of this patient. The Health Insurers denial should be upheld. Therefore, for the reasons stated above, 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 Upheld

Summary Reviewer 1
A 47-year-old male enrollee has requested authorization and coverage for endovenous vein ablation (CPT code 36478). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees varicose veins. The physician reviewer found that the documentation does not support the superior efficacy of the requested services in this clinical setting.  The patient does not present with significant symptoms. His presentation was for a duplex and a request for additional elastic stockings, which he found helpful.  There is no documentation that his symptoms are affecting his daily activities. The patient specifically notes that his occupation does not require him to stand or sit for prolonged periods of time. His symptoms of tingling in the thigh are unlikely to be addressed by ablation of his greater saphenous vein below the knee. Due to the relationship with the saphenous nerve, he is at increased risk for nerve related symptoms (tingling) following the procedure.  Additionally, it is not possible to attribute any of this patients leg symptoms to his residual varicose veins without an assessment of lower extremity arterial perfusion in the form of a pulse examination or noninvasive study. Therefore, endovenous laser vein ablation (CPT code 36478) is not likely to be more effective than the standard options available for the treatment of this patients medical condition.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 47-year-old male enrollee has requested authorization and coverage for endovenous vein ablation (CPT code 36478). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees varicose veins. The physician reviewer found that current Society for Vascular Surgery (SVS) and American Venous Forum (AVF) guidelines note the following recommendation, We recommend compression therapy as the primary treatment to aid healing of venous ulceration (GRADE 1B). To decrease the recurrence of venous ulcers, we recommend ablation of the incompetent superficial veins in addition to compression therapy (GRADE 1A) We recommend against selective treatment of perforating vein incompetence in patients with simple varicose veins (CEAP class C(2); GRADE 1B), but we suggest treatment of pathologic perforating veins (outward flow duration =500 ms, vein diameter =3.5 mm) located underneath healed or active ulcers (CEAP class C(5)-C(6); GRADE 2B). This patient was diagnosed with CEAP class 2, with no deep vein thrombosis, and no palpable pulses. In sum, endovenous laser vein ablation (CPT code 36478) is not likely to be more beneficial than the other treatment options available for the treatment of this patient.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 47-year-old male enrollee has requested authorization and coverage for endovenous vein ablation (CPT code 36478). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees varicose veins. The physician reviewer found that there is sufficient support in the medical literature and in the documentation provided for the requested services in this clinical setting. The patient has satisfied requirements with regard to symptom impact and conservative treatment use. The issue is the treatment of the perforator veins. There is good evidence to treat a symptomatic anterior accessory saphenous vein, whether by ablation or phlebectomy depending on the anatomy. In sum, endovenous laser vein ablation (CPT code 36478) is likely to be more effective for treatment of this patients medical condition than the standard therapy available.

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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 64-year-old male enrollee has requested authorization and coverage for PET scan with CT for attenuation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that PET/CT is one of the most useful imaging examinations for the staging of malignancy, detection of recurrence or metastases, and monitoring of treatment response. Although the value of PET/CT is limited for the diagnosis of renal cell carcinoma due to renal excretion of fluorodeoxyglucose (FDG), PET/CT has been increasingly utilized to evaluate treatment response to targeted therapies, such as tyrosine kinase inhibitors. It has been shown that tumor size is not an accurate indicator of tumor response to these new targeted therapies, and functional imaging is more accurate. In this case, the patient is not currently being treated with a tyrosine kinase inhibitor. A follow-up chest CT is the appropriate imaging examination to assess pulmonary metastases. The records indicate that the patient was evaluated with a CT of the chest on 4/12/19. The results were adequate for appropriate monitoring of the patient. Only if the results were substantially equivocal would a PET/CT be indicated, and they were not. Therefore, the requested PET with CT for attenuation is not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 53-year-old male has requested reimbursement for bronchial thermoplasty performed on 4/08/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the current medical evidence fails to demonstrate the medical necessity of the services at issue.  Bronchial thermoplasty is a procedure that uses a bronchoscope probe/catheter to provide thermal energy to the smooth muscle of the airway.  There are three bronchoscopic procedures.  The first procedure treats the right lower lobe.  The second procedure treats the left lower lobe, and the third bronchoscopic procedure is for both upper lobes.  The procedures are scheduled three weeks apart.  Bronchial thermoplasty is not generally accepted, standard of care for the treatment of asthma.  The appeal letter states the patient has a progressive decrease in the quality of life.  However, the available evidence does not demonstrate that bronchial thermoplasty would improve the long-term functional outcome of the patients condition.  All told, bronchial thermoplasty performed on 4/08/15 was not medically indicated for the treatment of this patient.  Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 60-year-old male enrollee has requested authorization and coverage for nerve stimulator implant. 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 this patient has obstructive sleep apnea. Drug-induced sleep endoscopy showed no concentric collapse at the palate or tongue base. The patient has not been able to tolerate continuous positive airway pressure (CPAP) therapy. The Inspire device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of obstructive sleep apnea. At this time, this patient is not a candidate for the Inspire device given his body mass index is greater than 32 and outside of FDA criteria. Very small studies have included patients with a body mass index greater than 32, but the number of the patients and data at this point in time is not adequate to consider standard. Therefore, the requested nerve stimulator implant is not likely to be superior over other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 60-year-old male enrollee has requested authorization and coverage for nerve stimulator implant. 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. This patient has failed continuous positive airway pressure (CPAP) therapy. He has attempted to use an oral appliance, with limited success. The medical evidence supports the requested services for patients who have failed CPAP therapy. Withrow and colleagues noted that apnea-hypopnea index (AHI) reduction and therapy usage were found to be somewhat higher among patients who were 65 years of age or older, and surgical complications with upper airway stimulation were low. In sum, the requested nerve stimulator implant is likely to be more effective than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 60-year-old male enrollee has requested authorization and coverage for nerve stimulator implant. 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 medical evidence supports the requested services in this case. This patient has an apnea-hypopnea index of 47. He is unable to tolerate continuous positive airway pressure (CPAP) therapy. Clinical studies of the use of hypoglossal nerve stimulation suggest that patients with a body mass index less than 35 benefit from this device. Huntley and colleagues noted that the device may be used successfully in patients with body mass index greater than 32. Upper airway stimulation is a safe and effective therapy for patients with obstructive sleep apnea and represents a powerful option for its surgical treatment. Thus, the requested nerve stimulator implant is likely to be superior over other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 51-year-old female enrollee has requested reimbursement for Avastin provided on 12/16/14, 1/6/15, 1/27/15, 2/17/15, and 3/10/15. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees recurrent metastatic breast cancer.  The physician reviewer found the patient was diagnosed with metastatic triple negative breast cancer in September 2014. The patient started treatment with Avastin, carboplatin, and Taxol. A scan done in December 2014 and compared to September 2014 revealed a marked response to therapy. The patient had significant side effects with the cytotoxic components of this regimen, which prompted discussion to proceed with single agent Avastin. There are adequate studies demonstrating the clinical efficacy of Avastin in this clinical setting. Further, this patients aggressive form of breast cancer demonstrated a very good response to therapy. All told, the Avastin provided on 12/16/14, 1/6/15, 1/27/15, 2/17/15, and 3/10/15 was medically necessary for treatment of this patients medical condition.