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

Summary Reviewer  A  55-year-old female enrollee has requested reimbursement for DecisionDX-melanoma laboratory testing performed on 5/13/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found that the staging and prognosis of cutaneous malignant melanoma is classically determined by the system spelled out by Balch and colleagues. There may be some further value in adding the mitotic rate to this system.  As per this system, this patient was staged as T1a, melanoma, with no mitoses seen. This would have an expected ten year survival of at least 88%.  There is no information in the records submitted as to whether she had sentinel node performed. DecisionDX, melanoma assay is a study of 31 genes in melanoma cells.  It then classifies that particular melanoma as either class 1 (with a 97% disease-free rate at five years) or class 2 (with a 31% disease free-rate at five years).  It is not clear how DecisionDX data compares to the ten year data of the Balch determinations, and whether it can be used to make clinical practice decisions.  This is particularly in question in this patients case given her pathologic findings and excellent prognosis.  All told, DecisionDX-melanoma laboratory testing performed on 5/13/16 was not likely to have been more effective than other modalities for evaluating this patient. Therefore, for the reasons stated above, the services at issue were not likely to have been 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 55-year-old female enrollee has requested reimbursement for DecisionDX-melanoma laboratory testing performed on 5/13/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found that a commercial gene expression profile test (DecisionDX-Melanoma) has been developed in patients with stage I and II cutaneous melanoma. However, 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, either as a standard of care or as part of clinical trials according to published data available. Per the National Comprehensive Cancer Network (NCCN) guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate benign from malignant neoplasms, or melanomas at low versus high risk for metastasis, routine (baseline) genetic testing of primary cutaneous melanomas is not recommended. At this time, the gene test performed on 5/13/16 was not likely to be of greater benefit than available standard therapy for the evaluation of this patient. Therefore, for the reasons stated above, the services at issue were not likely to have been 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 55-year-old female enrollee has requested reimbursement for DecisionDX-melanoma laboratory testing performed on 5/13/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found that the diagnostic test DecisionDX melanoma test is considered experimental. The test, using retrospective data, helps determine the risk of recurrence for early melanoma. The test lacks therapeutic implications as there is limited published data to support using adjuvant therapy in early stage I and II melanoma (lymph node negative) regardless of risk of recurrence. Furthermore, prospective randomized data for determination of risk of recurrence is lacking for this test. The scientific evidence does not support the superior efficacy of this test over standard options available for evaluation of patients in this clinical setting. Moreover, there is a lack of evidence that this technology improves the net health outcome.  As such, the DecisionDX-melanoma laboratory testing performed on 5/13/16 was not likely to have been more efficacious than other options available for evaluation of this patients medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been 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 


A 54-year-old female enrollee has requested reimbursement for inpatient hospitalization provided from 3/31/17 through 4/07/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who sustained injuries when she fell off a horse. The physician reviewer found that this patient presented status post a traumatic fall from a horse resulting in severe back pain. Clinical examination findings were consistent with imaging evidence of L1 and L3 acute compression fractures. She had severe pain that was not controlled with oral medications. She was admitted for inpatient care for pain control and observation on 3/31/17. She was placed on bed rest with bracing ordered. She continued to require intravenous medication due to inadequate relief with oral medications. She was very limited in her activity due to severe pain. Given the failure of closed treatment with bracing and continued severe pain with associated functional limitations, she underwent L1 and L3 vertebroplasty on 4/04/17. Following this procedure, she was able to ambulate with physical therapy, and oral pain medications provided adequate control as of 4/07/17. She was discharged to home on 4/07/17 with home health services. Evidence-based medical guidelines support hospitalization for parental narcotics and inability to manage basic activities of daily living at home, and additionally support a three-day best practice length of stay following vertebroplasty. Continued inpatient stay is supported until acceptable patient status for the next level of care is achieved, including pain is adequately managed on oral medications, and activity levels are at baseline or acceptable. Therefore, inpatient hospitalization provided from 3/31/17 through 4/07/17 was medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1
I have determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be upheld. The physician reviewer found that the patient is a 53-year-old male who complains of lumbar pain that started in 2012 after hot yoga. He had increasing back pain on and off over the last several years and has tried two facet injections, with no relief. The patient reported that a zero gravity chair is beneficial, and Kenalog injections reportedly provide temporary relief. The patient has requested reimbursement for mechanized spinal distraction therapy for low back pain provided on 4/26/18, 4/30/18, 5/01/18, 5/02/18, 5/03/18, 5/07/18, 5/08/18, 5/09/18, 5/10/18, 5/14/18, 5/15/18, 5/16/18, 5/17/18, 5/21/18, 5/22/18, 5/23/18, 5/24/18, 5/29/18, 5/30/18 and 6/04/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of this patient.

The current medical evidence has not demonstrated the superior efficacy of the services at issue. There is a lack of support for continuous or intermittent traction as a single treatment for patients with low back pain with and without sciatica. Clarke and colleagues noted, traction for patients with sciatica cannot be judged effective at present either, due to inconsistent results and methodological problems in most studies. Therefore, mechanized spinal distraction therapy for low back pain provided on 4/26/18, 4/30/18, 5/01/18, 5/02/18, 5/03/18, 5/07/18, 5/08/18, 5/09/18, 5/10/18, 5/14/18, 5/15/18, 5/16/18, 5/17/18, 5/21/18, 5/22/18, 5/23/18, 5/24/18, 5/29/18, 5/30/18 and 6/04/18 was not likely to have been of greater benefit than other available treatment options. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

I have determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be upheld. The physician reviewer found that the patient is a 53-year-old male with a history of low back pain. He received mechanized spinal distraction therapy for his low back pain. On 4/25/18, the patient reported that a zero gravity chair helps. The patient took gabapentin at night, and Kenalog injections reportedly provided temporary relief.  Significant objective findings included no ataxia and no shuffling gait, intact cranial nerves, and 2+ reflexes in the upper and lower extremities. Based on the letter dated 7/19/18, the patient reported that he has tried acupuncture and physical therapy. He has requested reimbursement for mechanized spinal distraction therapy for low back pain provided on 4/26/18, 4/30/18, 5/01/18, 5/02/18, 5/03/18, 5/07/18, 5/08/18, 5/09/18, 5/10/18, 5/14/18, 5/15/18, 5/16/18, 5/17/18, 5/21/18, 5/22/18, 5/23/18, 5/24/18, 5/29/18, 5/30/18 and 6/04/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of this patient.

Research does not show that lumbar traction is likely more beneficial for the patients condition compared to any available standard therapy. Schimmel and colleagues found that there was no difference between the Intervertebral Differential Dynamics Therapy and sham therapy 14 weeks after the start of the treatment neither for primary outcome nor for the secondary outcome. Both groups reported a significant improvement in low back pain, leg pain, and daily function. Thackeray and colleagues showed that patients with lumbar nerve root compression presenting for physical therapy can expect significant changes in disability and pain over 6-week treatment period and there is no evidence that mechanical lumbar traction in combination with an extension-oriented treatment is superior to extension-oriented exercises alone in the management of these patients. In sum, mechanized spinal distraction therapy for low back pain provided on 4/26/18, 4/30/18, 5/01/18, 5/02/18, 5/03/18, 5/07/18, 5/08/18, 5/09/18, 5/10/18, 5/14/18, 5/15/18, 5/16/18, 5/17/18, 5/21/18, 5/22/18, 5/23/18, 5/24/18, 5/29/18, 5/30/18 and 6/04/18 was not likely to have been of greater benefit than other available treatment options. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

I have determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be upheld. The physician reviewer found that the patient is a 53-year-old male who presented for a course of treatment on 4/25/18 for the diagnosis of lumbosacral intervertebral disc displacement. It was noted that the patients lower back pain began in 2012 after a hot yoga class.  Prior treatment reportedly included facet joint injections. On 4/26/18, the patient began a course of mechanized spinal distraction therapy. He has requested reimbursement for mechanized spinal distraction therapy for low back pain provided on 4/26/18, 4/30/18, 5/01/18, 5/02/18, 5/03/18, 5/07/18, 5/08/18, 5/09/18, 5/10/18, 5/14/18, 5/15/18, 5/16/18, 5/17/18, 5/21/18, 5/22/18, 5/23/18, 5/24/18, 5/29/18, 5/30/18 and 6/04/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of this patient.

There is a lack of support for the services at issue in this clinical setting. The records document a history of low back pain. The patients prior treatment included facet joint injections. Additionally, he has tried acupuncture and physical therapy. The medical literature has not demonstrated that mechanized spinal distraction therapy is superior over standard modalities for the treatment of this patient. Thus, mechanized spinal distraction therapy for low back pain provided on 4/26/18, 4/30/18, 5/01/18, 5/02/18, 5/03/18, 5/07/18, 5/08/18, 5/09/18, 5/10/18, 5/14/18, 5/15/18, 5/16/18, 5/17/18, 5/21/18, 5/22/18, 5/23/18, 5/24/18, 5/29/18, 5/30/18 and 6/04/18 was not likely to have been more effective than other treatment options. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 44-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/26/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination.  The physician reviewer found that there is evidenced base support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely to be more effective than had her examination been performed using two dimensional imaging alone. Based upon the information set forth above, the service at issue was likely to have been 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 44-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/26/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination.  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 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 particular patient, her breasts have been 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. Therefore, digital breast tomosynthesis performed on 9/26/16 was likely to have been of greater benefit 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 44-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/26/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination.  The physician reviewer found that there is sufficient support for digital breast tomosynthesis in the evaluation of this patient. The medical studies have shown that the addition of three dimensional digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening. Based upon the information set forth above, the service at issue was likely to have been 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 20-year-old male enrollee has requested authorization and coverage for residential substance use disorder treatment from 2/9/16 through 3/10/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The patient presented with a CIWA score of 1 which is consistent with having mild withdrawals. By 2/9/16, he was not a danger to himself or others. He was medically and psychiatrically stable. He did not require a detoxification protocol. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant a residential treatment services level of care.  The psychiatric evaluation indicated that his impulse control appeared to be good.  He was motivated and appeared to be working the program. Given his recent residential experience in August 2015, he had an educational exposure to relapse prevention, coping skills, and the 12 step program. His family was supportive in his efforts.  He did not require the 24 hour structure of residential and could have safely been treated at an ambulatory level of care such as an intensive outpatient program. As such, the residential substance use disorder treatment from 2/9/16 through 3/10/16 were not medically necessary. Therefore, for the reasons stated above, 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 Upheld

Summary Reviewer 1

A 55-year-old female enrollee has requested authorization and coverage for corticotropin (Acthar Gel). The Health Insurer has denied this request and reported that the requested medication is investigational 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 clinical setting. This patient has not exhausted all other possible therapies for rheumatoid arthritis, and the medical records do not clearly document that the patient has failed each therapy reported to have been tried and failed. Acthar Gel has not been proven to be superior to alternative therapies, such as prednisone or methylprednisolone, in terms of efficacy or safety for the long-term management of rheumatoid arthritis. Since Acthar Gel exerts at least some of its anti-inflammatory effects through corticotrophin receptors, Acthar Gel carries the same potential risks as steroids, including diabetes. 
H.P. Acthar has a corticotropin effect and with that, the same potential side effect profile as steroids with respect to osteoporosis, glaucoma, cataracts, weight gain, increased blood pressure, and glucose intolerance. Therefore, corticotropin (Acthar Gel) is not likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 55-year-old female enrollee has requested authorization and coverage for corticotropin (Acthar Gel). The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that the records document refractory rheumatoid arthritis and type 2 diabetes. She has tried and failed multiple medications, including nonsteroidal anti-inflammatory drugs (NSAIDs), high-dose intravenous corticosteroids, methotrexate, Enbrel, Arava, Plaquenil, Rituxan, Actemra, Xeljanz, Cimzia, Humira, Orencia, Imuran, Simponi, and Remicade. She has failed multiple tumor necrosis factor inhibitors and multiple biologic agents and continues to have active rheumatoid arthritis. In this case, the use of Acthar Gel would not be considered off-label, as Acthar Gel is approved for short-term use in rheumatological conditions, and this request is for six to eight weeks of therapy. She would need to be bridged to another medication. Short-term use would be consistent with current labeling and as a bridge to more definitive therapy. In sum, corticotropin (Acthar Gel) is likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 55-year-old female enrollee has requested authorization and coverage for corticotropin (Acthar Gel). The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient has been diagnosed with rheumatoid arthritis and has been treated with multiple medications, including anti-inflammatory drugs (NSAIDs), high-dose intravenous corticosteroids, methotrexate, Arava, Xeljanz, Actemra, and Orencia. Per the treating provider, she has developed either side effects to the tried medications or has not responded sufficiently in terms of disease activity to the medications. Acthar Gel is not a recommended treatment for rheumatoid arthritis. Furthermore, there is a paucity of objective data to support that the patient has had an inadequate response to other evidenced-based medications that have been tried previously. Per the last included treatment note from September 2019, objective findings included synovitis at one joint that was chronic, and no significant deformities of any joint. The submitted documentation fails to support the requested medication in this clinical setting. Thus, corticotropin (Acthar Gel) is not likely to be more beneficial than other treatment options.