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

Summary Reviewer 2

A 42-year-old female enrollee has requested reimbursement and prospective authorization and coverage for the Optune device with transducer arrays provided from 3/8/17 forward. The Health Insurer has denied this request indicating that the equipment at issue was and is considered investigational for treatment of the enrollees glioblastoma multiforme.   The physician reviewer found the patient is a 42-year-old female who initially underwent surgical resection for a glioblastoma. She went on to receive chemotherapy and radiation therapy and has started treatment with tumor treatment fields (TTF) with Optune. The patient has requested reimbursement and prospective authorization and coverage for the Optune device with transducer arrays provided from 3/8/17 forward. The Health Insurer has denied this request indicating that the equipment at issue was and is considered investigational. TTF with the Optune device is supported in the peer-reviewed medical literature for patients in the treatment of glioblastoma. One phase three study that examined the outcomes of patients with and without TTF found an improvement in survival (Stupp, et al). Moreover, TTF has not been associated with any major side effects. As a result, national guidelines from the National Comprehensive Cancer Network (NCCN) endorse the use of this device. Therefore, Optune device with transducer arrays provided from 3/8/17 forward was and is likely to be more beneficial for the treatment of the patients condition than standard therapy. Based upon the information set forth above, the equipment at issue was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 42-year-old female enrollee has requested reimbursement and prospective authorization and coverage for the Optune device with transducer arrays provided from 3/8/17 forward. The Health Insurer has denied this request indicating that the equipment at issue was and is considered investigational for treatment of the enrollees glioblastoma multiforme.  The physician reviewer found the patient is a 42-year-old female who is diagnosed with glioblastoma (GBM). A computed tomography (CT) of the head on 11/3/16 revealed a subtle density within the right frontal lobe. A brain magnetic resonance imaging (MRI) on 11/9/16 revealed a 1.4 x 1.1 x 1.0 cm enhancing right frontal lobe lesion. On 11/18/16, she underwent a craniotomy and resection. Pathology revealed GBM. She then received concurrent radiation and Temodar chemotherapy. Radiation was completed and she was recommended to undergo adjuvant tumor treatment fields (TTF) therapy. The patient has requested reimbursement and prospective authorization and coverage for the Optune device with transducer arrays provided from 3/8/17 forward. The Health Insurer has denied this request indicating that the equipment at issue was and is considered investigational. Optune TTF delivers alternating electric fields which disrupt mitotic activity. The device delivers electric fields via a portable device through electrodes placed on the patients scalp. TTF has been demonstrated to be an effective treatment for this patients disease, which is a disease in which few treatments have ever shown efficacy outside of standard surgery and radiation. It should be recognized that for TTF fields, the randomized data are from large multi-institutional studies by providers who specialize in the treatment of GBM. Thus, compared to other options, the Optune device with transducer arrays provided from 3/8/17 forward was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the equipment at issue was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 48-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 1/09/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees melanoma.The physician reviewer found that this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines state 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. Although this patient had high risk results, it is unclear how treatment and surveillance recommendations would be altered. Thus, DecisionDx-Melanoma testing provided on 1/09/18 was not medically necessary for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 63-year-old male enrollee has requested reimbursement and prospective authorization and coverage for Optune therapy (E0766) from 6/19/18 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 glioblastoma multiforme. The physician reviewer found that the current medical evidence supports the services at issue in this clinical setting. Optune (Novo-TTF) is a novel portable medical device which is worn on the scalp and generates low-intensity alternating electric fields. This was initially approved for use in the treatment of glioblastoma in 2011. Stupp and colleagues demonstrated that Optune is less toxic than Temodar, with the same overall survival statistics. The advantage of the combination of Optune with Temodar was reaffirmed in the review by Taphoorn and colleagues. All told, Optune therapy (E0766) from 6/19/18 forward was and is medically necessary for the treatment of this patient. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a 14-year-old female enrollee has requested reimbursement for psychiatric residential treatment center (RTC) services provided from 12/1/15 through 12/29/15. 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 that the psychiatric RTC services provided from 12/1/15 through 12/29/15 were not medically necessary for treatment of the patients behavioral health conditions. As of 12/1/15, the patient did not cause serious harm to herself or others. She did not require 24-hour supervision for psychiatric treatment. There was no reasonable expectation that the patients symptoms or level of functioning would have significantly improved with residential care. Moreover, the pharmacological changes, therapy progress notes, and treatment planning described do not demonstrate that the patient was exhibiting emotional distress or severe psychiatric symptoms that would require residential treatment. Less intrusive, and less invasive treatment options such as outpatient care could have been reasonably utilized. For the reasons provided, the psychiatric residential treatment center (RTC) services provided from 12/1/15 through 12/29/15 were not medically necessary for treatment of the patients medical condition. 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 23-year-old female enrollee has requested reimbursement for realignment of the right jaw joint (condylotomy) performed on 4/29/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the treatment of the enrollees temporomandibular joint pain. The physician reviewer there is sufficient support for the services at issue in this clinical setting.  This patient has been diagnosed with temporomandibular joint disease and was treated non-surgically.  However, this failed to resolve her symptoms.  The records document an internal derangement of her right temporomandibular joint with persistent symptoms.  The modified condylotomy is a well-known procedure with a high success rate.  The current medical evidence supports the services at issue in this clinical setting.  All told, realignment of the right jaw joint (condylotomy) performed on 4/29/16 was medically indicated 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 Overturned

Summary Reviewer 1
A 45-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 10/22/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that there is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. Due to the advantage tomosynthesis has brought to radiologists, particularly in cases of extremely and heterogeneously dense tissue such as the case under review, the American College of Radiology (ACR) has urged the technique be removed from the investigational category.  In particular, tomosynthesis has resulted in a decrease in callbacks and increase in detection of small cancers. In this case, the addition of tomosynthesis was likely of more benefit to this patient than had the exam been done with two-dimensional (2D) technique only. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 45-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 10/22/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the breast tomosynthesis performed on 10/22/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Skaane and colleagues performed a large prospective screening trial To assess cancer detection rates, false-positive rates before arbitration, positive predictive values for women recalled after arbitration, and the type of cancers detected with use of digital mammography alone and combined with tomosynthesis. The authors concluded that The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Given the support above, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients breast exam than conventional testing.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 45-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 10/22/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) 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 the dense breast tissue. In this case, the patient has breasts that have been described as being heterogeneously dense. Furthermore, the presence of dense breast tissue is an indication for tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Based on the clinical documentation submitted for review, the breast tomosynthesis performed on 10/22/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1
A 49-year-old female enrollee has requested reimbursement for endometrial ablation performed on 9/23/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that an endometrial ablation is a minimally invasive technique used to destroy the uterine lining for the treatment of chronic menorrhagia/abnormal uterine bleeding. This technique is supported by peer-reviewed current medical literature in patients who no longer desire fertility and in whom a thorough work-up has been performed to rule-out other causes of abnormal uterine bleeding. This evaluation includes performing a pelvic ultrasound and an endometrial biopsy/dilation and curettage (D&C). Furthermore, the patient should have tried and failed medical management options (such as birth control pills) over a reasonable period of time. Alternative treatment options, including hormones (pills, intrauterine device) and surgery, should be discussed. Based on review of this case, this patient had heavy menstrual cycles and cramping. The patient no longer desired fertility. She trialed a course of hormonal management with oral contraceptives. Per the available documentation, the patient has not responded to medical treatment and opted to undergo ablation. However, given the available clinical documentation, there is no evidence to support that the patient underwent a complete work-up to rule out other causes of abnormal uterine bleeding with endometrial sampling prior to the ablation. Therefore, endometrial ablation performed on 9/23/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 49-year-old female enrollee has requested reimbursement for endometrial ablation performed on 9/23/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the services at issue in this patientas case. The records note a history of heavy menstrual bleeding. This patient has opted for a minimally invasive option to control her bleeding. She has opted for an endometrial ablation. Minimally invasive treatment for heavy bleeding is encouraged in order to avoid more invasive treatment, such as hysterectomy. The current medical evidence supports an endometrial ablation in this clinical setting. The services at issue were likely to benefit the patient, with improved quality of life with decreased menstrual bleeding. Therefore, endometrial ablation performed on 9/23/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 49-year-old female enrollee has requested reimbursement for endometrial ablation performed on 9/23/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that this patient had a history of menorrhagia. One of the first steps in this setting is to perform an endometrial biopsy to rule out a malignancy or premalignant lesion and to determine what therapy is more appropriate. The submitted records do not document that an endometrial biopsy was performed. In women aged 40 years to menopause, abnormal uterine bleeding may be due to anovulatory bleeding, which represents normal physiology in response to declining ovarian function. It also may be due to endometrial hyperplasia or carcinoma, endometrial atrophy, and leiomyomas. Prior to performing an endometrial ablation, the structure and histology of the endometrial cavity should be thoroughly evaluated, both to assess for malignancy or endometrial hyperplasia and to ensure that the length and configuration is suitable for endometrial ablation. These parameters will vary depending on the technique or system used. Endometrial sampling, typically with an outpatient technique, can be used to evaluate all women for hyperplasia or malignancy, and results should be reviewed before ablation is scheduled. In this case, the records do not adequately document the need for an ablation. In addition, no hematocrit was submitted to assess the degree of bleeding. Many conservative options can be used in this setting prior to proceeding with an ablation. Nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce the amount of bleeding. Progestins and oral contraceptive pills are considered first-line treatment for abnormal, irregular or heavy bleeding. Ideally, the patient could use hormonal treatment for at least three months. If there is a failure to control the bleeding, then another option could be used. The provider stated that the enrollee did not tolerate oral contraceptives and did not respond to 10 days of a progestin. It may take more than 10 days to respond to a progestin, and there is no information when the oral contraceptives were used and what was the tolerance issue. The levonorgestrel-releasing intrauterine system has been shown to significantly reduce bleeding and cramping and may be used in the treatment for women with heavy abnormal bleeding. Tranexamic acid (Lysteda) is an antifibrinolytic taken during menstruation. It has been shown to be an effective treatment to decrease abnormal heavy uterine bleeding and improve quality of life. The patient has not tried this treatment. Therefore, there were multiple safe conservative treatment options available prior to proceeding with an ablation. Therefore, endometrial ablation performed on 9/23/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 63-year-old male enrollee has requested authorization and coverage for laparoscopy, surgical, esophagogastric fundoplasty (LINX). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found LINX Reflux Management System (LINX) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient has a diagnosis of persistent chronic GERD that has persisted despite treatment with proton pump inhibitor dosing and behavioral modification. The patient has a DeMeester score of 35 with evidence of Barretts per esophagogastroduodenoscopy (EGD). Treatment with the LINX procedure is indicated due to his persistent acid reflux and resulting in damage that will likely predispose him to adenocarcinoma. For the reasons provided above, the requested services are likely to be more beneficial for treatment of the patients medical condition than other modalities.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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


A 63-year-old male enrollee has requested authorization and coverage for laparoscopy, surgical, esophagogastric fundoplasty (LINX). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the request services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The LINX Reflux Management System is for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate GERD and a hiatal hernia less than 3 cm. Results from early studies at four years are encouraging. However, the requested procedure remains controversial as all studies to date have not included an appropriate control group. Additionally the bulk of the efficacy data is only from 1-3 years of follow-up. Therefore, the patients request for laparoscopy, surgical, esophagogastric fundoplasty (LINX) is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested 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 63-year-old male enrollee has requested authorization and coverage for laparoscopy, surgical, esophagogastric fundoplasty (LINX). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found according to Lipham and colleagues, Sphincter augmentation with the LINX Reflux Management System provided long-term clinical benefits as demonstrated by reduced esophageal acid exposure, improved GERD-related quality of life, and cessation of dependence on PPIs, with minimal side effects. Patients with inadequate symptom control with acid suppression therapy may benefit from treatment with sphincter augmentation. Moreover, according to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in regards to the safety and effectiveness of LINX Reflux Management System, On the basis of the available evidence, the LINX device should be an option available to patients and providers for the management of medically refractory GERD. In this case, the patient has GERD based on pH recording. However, in this case, the patient has both a large hiatal hernia and Barretts esophagus. There is a lack of studies supporting the LINX device for patients with these conditions. As such, the requested services are 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 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.