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

Summary Reviewer 2



A 36-year-old female enrollee has requested reimbursement for infliximab antibody testing performed on 3/30/15. 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 that management of ulcerative colitis using infliximab antibody testing has not been standardized, and recommendations for management based on test results (change to a different medication versus increase in dose) have not been formed (Kornbluth, et al). In addition, the use of infliximab antibody testing to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold drug levels been established (Steenholdt, et al). Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response (Vande Casteele, et al; Nanda, et al). A recent study concluded that prospective evaluation of the value of measuring serum concentrations of infliximab should be performed before these data can be included in patient management strategies (Adedokun, et al). Based on the clinical literature, the infliximab antibody testing performed on 3/30/15 was not 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 testing at issue was 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 36-year-old female enrollee has requested reimbursement for infliximab antibody testing performed on 3/30/15. 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 that the infliximab antibody testing performed on 3/30/15 was likely to be more effective for this patient than other available treatment options. Maximizing the efficacy of therapies for inflammatory bowel disease such as ulcerative colitis, while minimizing their toxicity remains the principal objective in developing management strategies. The loss of response to infliximab can be due to sub-therapeutic infliximab levels or the presence of antibodies to infliximab and performing this assay can be very useful in the management of the patients who are being treated with infliximab. In this case, the patient had a recent flare-up while being treated with Remicade and the infliximab antibody testing performed was indicated to assist with managing treatment strategies. 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

The patient is a 62-year-old female with a diagnosis of generalized anxiety disorder per the submitted documentation. The patient described her condition as complex trauma.  It appears that the patient has been working with a therapist in the outpatient setting. The trauma history, longitudinal illness burden, and extent and outcome of previous and/or concurrent treatment interventions were not included in the medical records. The patient has requested reimbursement and prospective authorization and coverage for standard outpatient treatment two times per week from 9/05/17 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of this patient. The Health Insurer has approved standard outpatient treatment once per week from 9/05/17 forward as an alternative. This denial is the subject of this appeal and determination. Psychotherapeutically, current practice emphasizes aggressive treatment of psychiatric symptoms in the acute phase of illness followed by less frequent services in the maintenance phase to foster patient autonomy and consolidate recovery.  Thus, it is not uncommon for transient weekly, or even twice- and thrice-weekly, sessions to be medically necessary in the treatment of anxiety and trauma-related disorders. The contemporary treatment armamentarium for both conditions offers many different evidence-based psychotherapies, such as cognitive processing therapy, prolonged exposure, eye movement desensitization and reprocessing, cognitive behavioral therapy, psychodynamic psychotherapy, mindfulness training and interpersonal therapy.  Regardless of the modality, any therapy must be reevaluated for effectiveness and goal progression during protracted treatment courses. With that in mind, the documentation provided in this particular case lacks critical clinical input to support the requested services. Most notably absent is a comprehensive treatment plan. An individualized and up-to-date treatment plan is a crucial patient-centric document that develops and organizes interventions aimed at maximizing functionality as well as helping a patient set specific goals and measurable objectives appropriate to his or her impairments and symptom severity. Based on the documentation provided, there is no evidence that less frequent clinical services, perhaps augmented with self-help programming and sub-clinical activities in the community, would be inadequate or unsafe to treat the patients condition. Further, weekly therapy visits align with community practice standards.  Accordingly, standard outpatient treatment two times per week from 9/05/17 forward were not and are not medically necessary for the treatment of this patient. Therefore, the services at issue were not and are 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 64-year-old female enrollee has requested reimbursement for FoundationOne test performed on 1/19/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer foound that the medical studies do not support the superior efficacy of the services at issue in this clinical setting. FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. However, there is a lack of evidence that the assay adds to the decision making ability of the provider, or yields a result that is clinically beneficial. There are various non-randomized studies exploring the value of molecular profiling but these studies are not definitive or compelling as to the efficacy of the assay. A study by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular targets. As such, the FoundationOne test performed on 1/19/17 was not likely to have been more efficacious than other methods of evaluating this patients medical condition. Therefore, for the reasons stated 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 64-year-old female enrollee has requested reimbursement for FoundationOne test performed on 1/19/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found that this patient has exhibited toxicity to a standard regimen for colon cancer. 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. A study by Von Hoff and colleagues involved 86 patients where the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. Accordingly, FoundationOne test performed on 1/19/17 was likely to have been of greater benefit than standard available methods of evaluating this patients medical condition. Therefore, for the reasons stated 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 Upheld

Summary Reviewer 3

A 64-year-old female enrollee has requested reimbursement for FoundationOne test performed on 1/19/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found that the medical literature has not established if molecular markers are useful in treatment determination as predictive markers and prognosis other than for KRAS, NRAS, and BRAF mutation testing and microsatellite instability (MSI) or mismatch repair (MMR) testing. This is supported by both the National Comprehensive Cancer Network (NCCN) guidelines and American Society of Clinical Oncology (ASCO). Although preliminary data from some clinical studies have fueled excitement about the value and utility of these studies, their execution has also provoked many questions about the best way to approach complicating factors such as tumor heterogeneity and the choice of which genetic mutations to target. To date it is unclear if molecular profiling is beneficial in identifying potential targets for treatment or if targets are identified whether or not targeted treatment is beneficial. In this patients case, there were other chemotherapy options available for adjuvant therapy including treatment with irinotecan. All told, the use of FoundationOne testing on 1/19/17 was not likely to have been of greater benefit than any other available standard therapy for evaluating this patients medical condition. Therefore, for the reasons stated 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 15-year-old female enrollee has requested reimbursement for acute inpatient mental health treatment provided from 2/13/20 through 3/19/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. In terms of risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to consistent deficits in ability to care for herself. With regard to functional status, the records support a score of 5. The patient had severe functional impairment as evidenced by severe weight loss due to refusal of food and nasogastric tube feedings, leading to dehydration and requiring medical hospitalization. In terms of comorbidity, the records support a score of 5 due to her medical status being compromised by food refusal. With regard to recovery environment, the records support a score of 3. The patient had a moderately stressful environment. The records noted serious illness for prolonged period, leading to months of hospitalization. In terms of environmental support, the records support a score of 2 due to her parents participation in treatment and treatment planning. With regard to resiliency and treatment history, the records support a score of 5. The records document persistence of symptoms despite past treatment at high levels of care for extended periods of time. In terms of treatment acceptance and engagement, the records support a score of 4. The patient refused medications and food and refused to cooperate with behavioral interventions. Therefore, the patient has a total score of 28. Due to severe functional impairment and severe comorbidity, the recommended level of care is medically managed residence-based services. This is consistent with the level of care offered in an inpatient setting. Therefore, acute inpatient mental health treatment provided from 2/13/20 through 3/19/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 45-year-old female enrollee has requested reimbursement for a sleep study performed on 12/11/14. The Health Insurer has denied this request indicating that the service at issue was not medically necessary for evaluation of the enrollees sleep disorder. The physician reviewer found in cases of mild OSA, home tests are occasionally noted to underestimate the severity of the medical condition rather than overestimate it.  In this case, the patient was reported to have been diagnosed with OSA via a home sleep test and was started on a CPAP machine. The CPAP was causing the patient more problems. In such cases, an attended polysomnography/sleep study would be warranted to determine the etiology of this paradoxical occurrence. In this patients case, the attended polysomnography/sleep study was medically necessary to assist in evaluating whether or not the patient had OSA. The medical literature indicates that the application of a CPAP machine, in some patients who do not have OSA, can lead to the development of central apneas. Ultimately, in this patients case, the performance of the attended polysomnography/sleep study provided findings/results that led to an improvement in the clients medical condition. By determining that she did not have OSA, the patient would no longer need to use the CPAP machine which had been exacerbating her respiratory issues during the day.  As a result, the service at issue was medically appropriate. Therefore, for the reasons stated above, the service at issue was medically necessary for the evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 51-year-old male enrollee has requested reimbursement for DecisionDX testing provided on 10/6/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees uveal melanoma.  The physician reviewer found choroidal melanoma is a relatively rare tumor which has consequences on both vision and lifespan. Metastatic disease prediction has been difficult and little data has been available to providers to educate the patient and to aid in the type and frequency of tests to order to follow the disease. With the DecisionDX assay the provider has a tool at their disposal to help predict the likelihood of metastatic disease and accordingly prescribe adjuvant therapy. The DecisionDX also helps provide a feasible schedule for the frequency of metastatic disease testing via laboratory and imaging studies. Given this support, the DecisionDX testing provided on 10/6/14 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, I have determined 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 2

A 51-year-old male enrollee has requested reimbursement for DecisionDX testing provided on 10/6/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees uveal melanoma.  The physician reviewer found uveal melanoma is a rare cancer that requires vigilant observation to detect clinical metastases early enough to undergo meaningful treatment. Uveal melanomas may be divided into two primary types, based upon gene expression. One of these types has a very low incidence of malignancy, while the other has a notably high rate. Once the type of the tumor can be determined, a clinical decision can be made as to how frequently the patient needs to undergo extensive medical surveillance and imaging for the remainder of their life. Currently, the DecisionDX has adequate support in the peer-reviewed medical literature for use in this clinical setting. Further, data suggests that the results are clinically significant and therefore important for patient care. The routine use of DecisionDX for uveal melanomas has been adopted by the vast majority of the tertiary care centers that treat this disease, thus making it the standard of care. For these reasons, the DecisionDX testing provided on 10/6/14 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, I have determined 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 51-year-old male enrollee has requested reimbursement for DecisionDX testing provided on 10/6/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees uveal melanoma.  The physician reviewer found there is convincing scientific evidence that genetic testing of uveal melanoma tumor can stratify the tumors into high and low risk for systemic metastasis (Field and Harbour). The key questions are whether having this information is needed for an individual patient and whether it alters the course of treatment. Currently, this test is part of the standard of care in these patients in this clinical setting (Shields and Shields). Given this support, the DecisionDX testing provided on 10/6/14 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, I have determined 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 

The parent of a 16-year-old transgender male enrollee has requested authorization and coverage for 19350 (nipple/areola reconstruction). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees gender dysphoria. The physician reviewer found that chest surgery for transmasculine youth is a common intervention for gender dysphoria. There is no justification for limiting coverage for treatment to adults. The World Professional Association for Transgender Health (WPATH) notes that chest surgery in transgender males could be carried out earlier [than age 18], preferably after ample time of living in the desired gender role and after one year of testosterone treatment. In this case, the patient has had ample time living as male and is on testosterone. Chest surgery is a safe and effective treatment for gender dysphoria in transmasculine youth. Olson-Kennedy and colleagues stated, Chest dysphoria was high among transmasculine youth, and surgical intervention positively affected both youth and adults. The current medical evidence supports the requested services in this patients case. Therefore, 19350 (nipple/areola reconstruction) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a 16-year-old female enrollee has requested reimbursement for mental health inpatient treatment provided from 11/24/15 through 11/30/15. 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 the submitted documentation demonstrates the medical necessity of the services at issue. 
On 11/24/15, the patients Zoloft and Abilify dosages were increased, as she was still depressed. Furthermore, she had been placed on one to one staffing because of self-abusing. The records reflect that the patient was still unstable. The submitted documentation supports the continuation of this patients inpatient treatment in order to stabilize her prior to discharge. In addition, the patients recent history of decompensation after stepping down for only a few days to PHP further increased the likelihood of a relapse if she were discharged from acute care prematurely.  All told, the services at issue were medically prudent and necessary in the treatment of the patients behavioral health condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a four-year-old male enrollee has requested reimbursement and prospective authorization and coverage for occupational therapy services provided on 11/19/16 through 12/21/16, and forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees feeding and eating difficulties. The physician reviewer found that as noted by Manikam and Perman, the consequences of feeding disorders can be severe and treatment can include treatment of the medical condition, behavioral modification to alter the childs inappropriate learned feeding patterns, and parent education and training in appropriate parenting and feeding skills. This patient has made progress and continues to make progress with his current occupational therapy services. The patient should be able to continue occupational therapy until he has made further progress and the provider finds that he is at his maximum potential. Accordingly, the occupational therapy services provided on 11/19/16 through 12/7/16, and forward were and are medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.