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

Summary Reviewer 1

A 41-year-old male enrollee has requested reimbursement for elastase pancreatic fecal and fecal calprotectin laboratory testing performed on 8/03/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The records document diarrhea-predominant irritable bowel syndrome. This patients provider ordered fecal calprotectin testing to rule out intestinal inflammation and fecal elastase testing to assess for pancreatic insufficiency. Based on the records, careful patient interview and examination may have yielded better targeted studies. In the evaluation of chronic diarrhea, fecal calprotectin is sometimes used in clinical practice to distinguish inflammatory versus functional causes of diarrhea, particularly in pediatric populations. The records do not support concern for inflammatory bowel disease in this patients case. Therefore, fecal calprotectin laboratory testing performed on 8/03/18 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 41-year-old male enrollee has requested reimbursement for elastase pancreatic fecal and fecal calprotectin laboratory testing performed on 8/03/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the records do not document the superior effectiveness of the services at issue. Fecal calprotectin is a useful test as a quantitative measure of inflammation within the gastrointestinal tract. It is useful to distinguish patients with irritable bowel syndrome versus inflammatory bowel disease and can allow patients to avoid unnecessary colonoscopy. However, this patient underwent this test the year before, and the records do not demonstrate the need to repeat this test. In sum, fecal calprotectin laboratory testing performed on 8/03/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 41-year-old male enrollee has requested reimbursement for elastase pancreatic fecal and fecal calprotectin laboratory testing performed on 8/03/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this clinical setting. The records document chronic diarrhea. This patients symptoms included abdominal bloating, intermittent watery diarrhea and rectal itching. The documentation noted that the patient tested negative for celiac disease in the past. Expert guidelines for the evaluation of chronic diarrhea have recommended fecal calprotectin testing in the evaluation of diarrhea, as a surrogate for fecal leukocyte testing. This testing can identify whether an inflammatory cause for diarrhea is present. Thus, fecal calprotectin laboratory testing performed on 8/03/18 was likely to have been more effective than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 52-year-old female enrollee has requested authorization and coverage for a PET scan. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines recommend conventional imaging of the chest, abdomen and pelvis using computed tomography (CT) as well as a radionuclide bone scan every two to six months for patients with recurrent breast cancer to the chest wall and solid organs as surveillance. PET/CT is usually is done when there are equivocal or suspicious findings suggestive of metastatic disease. The physiologic nature of a PET scan is used to confirm or exclude likely tumor recurrence. Piva and colleagues noted that PET/CT imaging can be useful when there are equivocal findings on conventional imaging. In this patients case, the medical necessity of PET/CT every three months has not been established since there has been no evidence of distant metastases in the past, and there are no conventional imaging reports after recent surgical and radiation treatment to suggest equivocal or suspicious findings. Therefore, the requested PET scan is not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 49-year-old female enrollee has requested reimbursement for Tempus xT gene panel performed on 3/16/20.  The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that individualized molecular tumor profiling holds the promise of enabling personalized selection of molecularly targeted treatment based on the specific genotype identified. Several platforms are available, including the Tempus gene panel. The National Comprehensive Cancer Network guidelines recommend tumor molecular testing prior to initiation of therapy for recurrent or persistent ovarian cancer, if not previously done. Molecular profiling is now considered a standard of care in patients with recurrent or persistent ovarian cancer. There is sufficient support for the services at issue in this clinical setting. Therefore, the Tempus xT gene panel performed on 3/16/20 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 49-year-old female enrollee has requested reimbursement for Tempus xT gene panel performed on 3/16/20.  The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that Tempus is one of a number of multigene and molecular features assay of an individuals cancer cells. The hope is that it will indicate a specific drug that can target a mutation or molecular target. However, thus far, there is no clear data to indicate that using the assay in that way can reliably yield a treatment with significant clinical benefit. A randomized study by Le Tourneau and colleagues did not find that picking a treatment based on such an assay is superior to that using the oncologists judgment. Several reports indicate that the benefit from using such an assay is rare and unlikely. Therefore, the Tempus xT gene panel performed on 3/16/20 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 49-year-old female enrollee has requested reimbursement for Tempus xT gene panel performed on 3/16/20.  The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient has advanced ovarian cancer. She has been appropriately treated with debulking surgery and multi-agent chemotherapy. Close follow-up has revealed progressive disease. According to the National Comprehensive Cancer Network guidelines and the National Cancer Institute Physicians Data Query, it will be important to know the presence of germline or somatic mutations in BRCA1 and/or BRCA2. She may be offered certain therapies based upon mutation status. The patient may also be eligible for clinical trials based on her mutational status. It is notable that the National Comprehensive Cancer Network guidelines support testing for BRCA1 or BRCA2 mutations as well as other assays that might evaluate for homologous recombination defects. The National Comprehensive Cancer Network noted that pathologic assessment should include tumor molecular analyses as clinically indicated. Per the National Comprehensive Cancer Network guidelines, this includes next generation sequencing for BRCA1/2 mutations, other somatic mutations (e.g., NTRK gene fusions), and tumor mutational burden. These assessments were part of the ordered laboratory test. Therefore, the Tempus xT gene panel performed on 3/16/20 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 61-year-old female enrollee has requested authorization and coverage for positron emission tomography (PET) scan. The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees lung cancer. The physician reviewer found that of the original indications for PET scan was the evaluation of solitary pulmonary nodules to determine the likelihood of malignancy based on high standardized uptake values (SUV). Primary lung cancer greater than 1 cm in diameter has a very high true positive rate on PET/CT versus other post therapy and infectious etiologies. In this patient with a question of recurrent lung cancer versus scar formation and the contraindication of biopsy of the lesion due to severe COPD, PET scan is likely to be more beneficial than other methods of evaluating this patient. Based upon the information set forth above, the requested services are 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 61-year-old female enrollee has requested authorization and coverage for positron emission tomography (PET) scan. The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees lung cancer. The physician reviewer found that The National Comprehensive Cancer Network (NCCN) has established guidelines for the initial work-up and then treatment and surveillance for small cell lung carcinoma.  The initial work-up will often include, among other modalities, a PET/CT scan. When there is evidence of a new nodule or mass, the NCCN recommends that the patient be re-evaluated as if the new mass could be a new primary tumor. This initial evaluation would likely include a PET/CT scan. In this patients case, PET scan is likely to alter management.  If the PET scan were to show metabolic activity, it is likely that the patient will undergo another round of chemotherapy. A strikingly high standardized uptake value (SUV) will indicate tumor. All told, the requested PET scan is likely to be superior over other methods of evaluating this patient. Based upon the information set forth above, the requested services are 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 61-year-old female enrollee has requested authorization and coverage for positron emission tomography (PET) scan. The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees lung cancer. The physician reviewer found that small cell lung carcinoma (SCLC) is an aggressive pulmonary neuroendocrine neoplasm. Typical treatment for limited stage SCLC typically involves a combination of chemotherapy and radiation therapy, as in this case. PET/CT combines functional/metabolic as well as anatomic information and is utilized in the setting of SCLC to guide initial treatment strategy or modify treatment. The National Comprehensive Cancer Network (NCCN) recommends post-treatment surveillance of non-surgical lung cancer with chest CT approximately every six months or more frequently in some cases. PET-CT is not routinely recommended in cases where there is no radiographic sign of disease. However, the guidelines state that it may be useful in assessing abnormalities seen on CT scan which are indeterminate, and may represent post-treatment changes or recurrence. In this case, the results of the patients most recent CT scan in May 2018 were suspicious for disease recurrence, although nonspecific. As stated in the NCCN guidelines, PET is the recommended next test to clarify inconclusive CT results and determine if biopsy is necessary. As biopsy is risky in this patient due to severe underlying lung disease, it should only be performed if absolutely necessary. Thus, the requested PET scan is likely to be more efficacious than other modalities for evaluating this patient. Based upon the information set forth above, the requested services are 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 54-year-old male enrollee has requested reimbursement for inpatient stay provided from 11/05/18 through 11/07/18. 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 the submitted documentation supports the services at issue in this clinical setting. The patient had exertional dizziness and some recent chest discomfort. His electrocardiogram showed evidence of prior inferior myocardial infarction. He has cardiovascular risk factors of hypertension and hyperlipidemia, and an echocardiogram showed evidence of inferior wall motion abnormalities consistent with the myocardial infarction noted on electrocardiogram. Given the evidence of prior myocardial infarction and his other risk factors, the index of suspicion for ischemic origin of symptoms is much higher, and admission for an ischemic work-up for possible acute coronary syndrome is necessary, given the known coronary artery disease. Given the patients symptoms, his cardiovascular risk factors, and the objective findings on both the electrocardiogram and echocardiogram of prior myocardial infarction and coronary artery disease, an inpatient evaluation for recurrent ischemia was medically necessary, as this is an objectively higher risk patient. Therefore, inpatient stay provided from 11/05/18 through 11/07/18 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 59-year-old enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/20/20. 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 there is a lack of support for the services at issue in this clinical setting. Prognostic gene expression profiling (GEP) testing to differentiate melanomas at low versus high risk for metastasis should not replace pathologic staging procedures. Moreover, since there is a low probability of metastasis in stage I melanoma and a higher proportion of false-positive result, GEP testing should not guide clinical decision making in this group. Commerically available GEPs are marketed as being able to classify cutaneous melanoma into separate categories used on risk of metastasis. However, it remains unclear where these GEP platforms provide clinically actionable prognostic information when used in addition to or in comparison with known cliniopathologic factors or multivariate nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. It remains unclear whether this GEP profile is reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation studies are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and, in particular, to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Therefore, DecisionDx-Melanoma testing performed on 4/20/20 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 59-year-old enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/20/20. 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 Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Therefore, DecisionDx-Melanoma testing performed on 4/20/20 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 59-year-old enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/20/20. 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 the staging and classification of cutaneous melanoma has classically been described by Balch. Mitotic index has been thought to add a bit to the statistics. DecisionDx-Melanoma testing is an assay of 31 genes in the cells of an individualas melanoma cells. It then classifies that melanoma based on the five-year risk of metastasis. It is not known how the five-year DecisionDx-Melanoma testing data compares to the 10-year Balch data. Additionally, it is not clear if the DecisionDx-Melanoma classification can be used to make therapeutic decisions, such as whether to do a sentinel node and/or give adjuvant therapy. Therefore, DecisionDx-Melanoma testing performed on 4/20/20 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 58-year-old female enrollee has requested authorization and coverage for Ibrance 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees breast cancer.  The physician reviewer found that this patient has hormone receptor positive breast cancer that has metastasized to her bones, nodes, and lung. She has already been treated with an aromatase inhibitor. Ibrance in combination with Faslodex is considered a standard of care for patients with metastatic hormone positive breast cancer after progression on an aromatase inhibitor as this patient. Ibrance is also supported by the National Comprehensive Cancer Network (NCCN) guidelines as well as U.S. Food and Drug Administration (FDA) approved for this indication. For these reasons, the requested Ibrance 100 mg 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 requested medication 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 2


A 58-year-old female enrollee has requested authorization and coverage for Ibrance 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees breast cancer.  The physician reviewer found that Turner and colleagues reported that treatment with Ibrance and Faslodex is approved for ER positive metastatic disease. The authors reported that among patients with hormone receptor positive metastatic breast cancer who had progression of disease during prior endocrine therapy, Ibrance combined with Faslodex resulted in longer progression-free survival than Faslodex alone. Given this support, the requested Ibrance 100 mg is 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 medication 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 58-year-old female enrollee has requested authorization and coverage for Ibrance 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees breast cancer.  The physician reviewer found that Ibrance inhibits Cyclin-dependent kinases 4 and 6 (CDK4, CDK6), which may account for resistance to endocrine therapy and has been U.S. Food and Drug Administration (FDA) approved for first-line therapy of estrogen receptor (ER) positive, HER2 negative metastatic breast cancer in postmenopausal women in combination with letrozole. Turner and colleagues reported that in the PALOMA-1 trial, 165 patients were randomized to letrozole or letrozole with Ibrance and the latter regimen conferred increased progression-free survival of 20.2 months versus 10.2 months, a finding of high statistical significance. Overall, there is sufficient medical evidence to suggest that Ibrance is appropriate for this patient who has progressed on standard regimens. As such, the requested Ibrance 100 mg 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 requested medication 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.