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

Summary Reviewer 


A 63-year-old female enrollee has requested reimbursement for air ambulance transport services provided on 3/30/14. 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 that according to the documentation submitted for review, a then relatively healthy 61-year-old female sustained an isolated closed distal femur fracture after falling down an embankment. She was brought to ED where the record reports orthopedic surgical care was unavailable. According to the American Academy of Orthopedic Surgeons (AAOS) practice guidelines femur fracture in the elderly should be treated with urgency (within 48 hours). The decision to transfer care to another center was therefore appropriate, as there was no indication when orthopedic care would be available. However, the decision to transfer to a center in Santa Rosa, as opposed to the closer facility in Redding is not entirely clear, based on the submitted records. There is no statement as to whether or not orthopedic surgical was available in Redding. Regardless, there is a lack of documentation that the patient was hemodynamically unstable. In addition, the patient did not meet the criteria guidelines from the American College of Emergency Physicians to warrant air medical dispatch. Traction splinting in the field and ground transport is sufficient for stable patients with isolated femur fractures. Spiral fracture patterns, as reported in the submitted records, can occur with relatively low energy mechanisms, particularly in the elderly, and associated complications such as compartment syndrome in these types of fractures is extremely low. In addition, based on the records, the air transport did not significantly shorten the time to definitive care. In this case, the use of air ambulance transport services provided on 3/30/14 was not medically necessary. 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 Upheld

Summary Reviewer 1

A 24-year-old male enrollee has requested reimbursement for services provided from 5/10/15 through 8/05/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  There is a lack of convincing evidence of superior treatment of wilderness therapy to standard accepted therapies.  Bettmann and colleagues reported that wilderness therapy research is significantly lacking in controlled studies. Widmer and colleagues reported that although some studies report benefits of wilderness therapy, caution should be exercised in the interpretation of these results.  There is a lack of studies proving that wilderness therapy is more beneficial for treatment of social pragmatic communication disorder and unspecified neurodevelopmental disorder. Therefore, the services provided from 5/10/15 through 8/05/15 were not likely to have been of greater benefit 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 Upheld

Summary Reviewer 2

A 24-year-old male enrollee has requested reimbursement for services provided from 5/10/15 through 8/05/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees behavioral health conditions. The physician reviewer found the reason for entry into a wilderness program is unclear.  There is no admitting history or intake, and the records do not document that he was seen by a physician of any specialty. There is no prior psychiatric history. It is unknown if other treatment modalities were attempted in the past at lower levels of care and what those outcomes were.  Mental status examinations were not performed and response to medications does not appear to have been assessed.  In sum, the records do not establish that services provided from 5/10/15 through 8/05/15 were likely to have been more efficacious than other treatment alternatives.  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

A 24-year-old male enrollee has requested reimbursement for services provided from 5/10/15 through 8/05/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees behavioral health conditions. The physician reviewer found there is substantial literature to support the use of cognitive behavioral therapy for the patients symptoms.  However, the literature for wilderness adventure therapy programs is not robust in relation to treating these issues.  The majority of the literature on the wilderness adventure therapy programs is for children and adolescents.  In this patients case, it is not clear that less restrictive resources were not available or appropriate for the patients needs. The documentation does not support failure of outpatient therapy, intensive outpatient therapy, partial hospital program therapy or cognitive behavioral therapy.  Based on the records, it is not clear that the services provided would have been more beneficial than typical evidence-based treatments for the patients anxiety issues as well as his functional issues due to his anxiety. The patient also had social skills and language deficits that were a main focus of treatment. The documentation does not support failures of community-based services and evidence based treatments, such as cognitive behavioral therapy, which is a mainstay for anxiety and social anxiety symptom treatment.  Behavioral health therapy should be started in the least restrictive and most similar to home-type environment available. This is due to the fact that skills learned in therapy will generalize better to a home-type environment. Skills learned in an artificial environment are known to not generalize as well as those learned in a home-type environment.  In this patients case, he could have safely been treated in a less restrictive setting.  Thus, services provided from 5/10/15 through 8/05/15 were not likely to have been superior over other treatment alternatives in this patients case.  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 1

A 49-year-old female enrollee has requested reimbursement for Guardant360 CDx testing performed on 3/22/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that inoperable advanced pancreatic cancer is an incurable disease, but chemotherapy can prolong survival. The genetic mutations that are present can provide prognostic significance and can help direct therapy. Mutational analysis is also part of the algorithms that are included within the National Comprehensive Cancer Network (NCCN) guidelines, but this is restricted to testing on the primary tumor samples. According to the NCCN guidelines, aGermline testing is recommended for any patient with confirmed pancreatic cancer, using comprehensive gene panels for hereditary cancer syndromes. Genetic counseling is recommended for patients who test positive for a pathogenic mutation or for patients with a positive family history of cancer, especially pancreatic cancer, regardless of mutation status.a According to the NCCN guidelines, aTesting on tumor tissue was preferred; however, cell-free DNA testing can be considered if tumor tissue testing is not feasible.a The NCCN guidelines goes on to say, aData are not available to show that earlier treatment of recurrences, following detection by increased tumor marker levels or CT scan, leads to better patient outcomes.a The Guardant360 test is a liquid biopsy that analyzes patient plasma for mutations in a panel of 70 genes. In this case, Guardant360 CDx testing was not done to analyze mutational analysis of an existing recurrence or an existing mass. Instead, it was performed to look for recurrence. This is not a medically appropriate use of the test. Therefore, Guardant360 CDx testing performed on 3/22/21 was not likely to have been more beneficial for evaluation of the patientas condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 49-year-old female enrollee has requested reimbursement for Guardant360 CDx testing performed on 3/22/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that the NCCN guidelines recommend next generation sequencing (NGS) for pancreatic cancer patients. However, testing on tumor tissue is preferred. This patient did undergo NGS sequencing of the tumor removed at initial surgery and has had liquid NGS with Guardant360 in the past as well. Although serial liquid biopsy has been shown to help predict prognosis, its impact on therapeutic decision-making has not been demonstrated. Its role in the treatment of pancreatic cancer has yet to be defined. There is a lack of support for the use of serial liquid NGS at this time. Therefore, Guardant360 CDx testing performed on 3/22/21 was not likely to have been more beneficial for evaluation of the patientas condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 49-year-old female enrollee has requested reimbursement for Guardant360 CDx testing performed on 3/22/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that based on the records, this patient had two previous molecular assays. Thus, the services at issue were the third such assay. There is a lack of convincing data to demonstrate that in pancreatic cancer, choosing chemotherapy by molecular assay is superior to standard decision making. Although NCCN guidelines note the possible value of determining certain mutations in pancreatic cancer, there is no reason to believe that a third such assay would be of clinical benefit. As noted by Marquardt, the percentage of patients who benefit from such genome-based therapeutics appears to be quite low. Therefore, Guardant360 CDx testing performed on 3/22/21 was not likely to have been more beneficial for evaluation of the patientas condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 22-year-old male enrollee has requested reimbursement for inpatient detoxification services provided from 2/23/18 through 2/28/18. 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 in cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 2 due to a lack of current suicidal ideation with active intent or plan. The records noted that the patient had suicidal ideation which had resolved. With regards to functional status, the records support a score of 3 due to overall fair functional level in treatment but a history of functional problems when in the community and a history of using substances. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and history of mood symptoms and attention/deficit hyperactivity disorder. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable living environment with family. In terms of level of support of the recovery environment, the records support a score of 2 due to an overall supportive recovery environment. With regards to treatment and recovery history, the records support a score of 3 due to current motivation for treatment but unclear response to treatment in the past. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment. Thus, the patient has a composite score of 16. This score correlates with low intensity community-based services. Therefore, inpatient detoxification services provided from 2/23/18 through 2/28/18 were not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 67-year-old male enrollee has requested reimbursement for gene testing performed on 4/19/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees metastatic renal cell carcinoma. The physician reviewer found that FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers that can help guide therapy decision making. Per the National Comprehensive Cancer Network guidelines, it has not been determined if molecular markers are useful in treatment determination (predictive markers) and prognosis. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. At this time, the superior efficacy of gene testing performed on 4/19/16 has not been established.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 67-year-old male enrollee has requested reimbursement for gene testing performed on 4/19/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees metastatic renal cell carcinoma. The physician reviewer found the National Comprehensive Cancer Network guidelines list numerous first-line and second-line treatment options for clear cell kidney cancer (renal cell cancer.) These include temsirolimus and everolimus. None of them require genetic testing. The discussion section of the guidelines do not mention the use of next generation sequencing such as FoundationOne testing. There is a proposed clinical trial evaluating next generation sequencing that will include kidney cancer patients. It is not yet accruing patients. At this time, there is a lack of data to support that gene testing performed on 4/19/16 was likely to have been more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 67-year-old male enrollee has requested reimbursement for gene testing performed on 4/19/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees metastatic renal cell carcinoma. The physician reviewer found that metastatic renal cell cancer is resistant to conventional chemotherapy. The provider ordered somatic cancer mutational testing in an effort to decide the next best therapy. Patients with refractory or relapsed cancer that 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 the progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. In this patients case, VHL, MTOR mutations and CDKN2A/B loss were notable aberrations. This does suggest targeted therapy with an mTOR inhibitor may be utilized. Everolimus is an inhibitor of the mammalian target of rapamycin (mTOR) kinase, and placebo controlled clinical trials support its use in renal cell carcinoma. There is sufficient support for the services at issue in this clinical setting. Thus, gene testing performed on 4/19/16 was likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 42-year-old female enrollee has requested authorization and coverage for Aimovig 140 mg dose, two auto-injections. 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 Aimovig has been approved by the U.S. Food and Drug Administration for migraine headache.  This patient has failed numerous first-line therapies for headache. More recently, she has demonstrated benefit with Aimovig. There is sufficient medical evidence supporting the use of Aimovig for patients with chronic headache. It would not be in this patients best interest to be required to discontinue Aimovig in favor of another medication (Botox) which may have possible side effects for this patient. Continued use of Aimovig is medically reasonable and indicated in this case. Therefore, Aimovig 140 mg dose, two auto-injectors are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 64-year-old male enrollee has requested authorization and coverage for cetuximab (Erbitux) to be given in conjunction with FOLFIRI. The Health Insurer has denied this request and reported that the requested medication regimen is investigational for the treatment of the enrollees medical condition. The physician reviewer found that Erbitux (cetuximab) is a monoclonal antibody targeting EGFR. It has been approved in several types of cancer, usually when given with chemotherapy or radiation therapy. The literature as to its use in esophageal cancer does not demonstrate convincing evidence of its efficacy. The randomized trial by Suntharalingam and colleagues did not demonstrate benefit to cetuximab when added to chemoradiation therapy in localized disease. Huang and colleagues noted that cetuximab failed to significantly improve the overall survival and progression-free survival for patients with localized or metastatic esophageal cancer. Overall, there is a lack of convincing data to indicate the usefulness of cetuximab in esophageal cancer. Therefore, cetuximab (Erbitux) to be given in conjunction with FOLFIRI is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 64-year-old male enrollee has requested authorization and coverage for cetuximab (Erbitux) to be given in conjunction with FOLFIRI. The Health Insurer has denied this request and reported that the requested medication regimen is investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient has a very poor prognosis disease, a gastroesophageal junction cancer with regional metastases and progression on standard multi-agent chemotherapy. His tumor was submitted for mutational analysis. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Von Hoff and colleagues performed a pilot study of 86 patients, and 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. In this case, the analysis revealed marked amplification of the EGFR gene. The EGFRs have multiple oncogenic roles in gastroesophageal junction tumors. In this patients case, the oncologist has recommended FOLFIRI in combination with cetuximab. There is significant evidence that cetuximab can lead to a durable response in patients with EGFR amplification. Therefore, cetuximab (Erbitux) to be given in conjunction with FOLFIRI is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 64-year-old male enrollee has requested authorization and coverage for cetuximab (Erbitux) to be given in conjunction with FOLFIRI. The Health Insurer has denied this request and reported that the requested medication regimen is investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is no globally accepted first-line chemotherapy regimen for advanced, HER2-negative esophagogastric cancer, and practice is variable. Cetuximab in EGFR amplified tumors has been shown to be effective in patients with esophageal and gastric cancers and has been demonstrated to be well-tolerated in combination with fluorouracil based chemotherapy rather than other regimens. This patient is receiving first-line therapy for metastatic disease given prior treatment in 2006. There is sufficient support for the requested medication regimen in this setting. Thus, cetuximab (Erbitux) to be given in conjunction with FOLFIRI is likely to be more beneficial than any available standard therapy.