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

Summary Reviewer 3


The parent of a 16-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 12/13/13. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees ulcerative colitis.The physician reviewer found the use of Anser IFX testing was appropriate in this patient case, to determine whether his clinical worsening was due to inadequate infliximab dosing, neutralization of the medication by antibodies, or loss of response to the medication. The use of infliximab levels and antibodies is supported by the medical literature. The studies indicate that measurement of infliximab levels and anti-infliximab (anti-chimeric) antibodies produces actionable data (Afif et al; and Yanai and Hanauer). Change of dose or drug based on these results improves response to treatment, as measured by clinical response. The study by Hoekman and colleagues demonstrates that lower infliximab troughs are associated with elevated markers of mucosal inflammation in children. The studies cited above support the use of infliximab levels and antibody measurements in the setting of inadequate clinical response to treatment, as well as for monitoring effectiveness of dose escalation.  The alternative is to sequentially increase dose and decrease dosing frequency of infliximab, then empirically change to another medication, typically adalimumab, if lack of response persists. This clinical approach can be lengthy and can prolong a patients symptoms as well as the likelihood of an intercurrent hospital admission. Therefore, Prometheus Anser IFX diagnostic testing performed on 12/13/13 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 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 62-year-old female enrollee has requested authorization and coverage for Xeljanz.A review of the record indicates that the enrollee has been diagnosed with alopecia areata. In an
undated letter, the provider reported that the enrollee has tried squaric acid, Rogaine, and
intralesional Kenalog injections.The Health Insurer indicates that the requested medication is investigational for the evaluation of
the enrolleeas medical condition. Therefore, the Health Insurer has denied coverage for the
requested medication. The physician reviewer found that available treatment options for alopecia areata (AA) are limited. This is especially true for diffuse
involvement, where standard therapies such as topical steroids, intralesional kenalog, contact
immunotherapy and conventional immunosuppressants (systemic steroids, methotrexate and
cyclosporine) are more often than not less than satisfactory and associated with side effects.
Although there is no significant data yet from randomized clinical trials (which are currently
underway), there is substantial clinical evidence to support the use of oral JAK kinase inhibitors
such as tofacitinib for alopecia areata. In an open label pilot study by Jabbari and colleagues, eight
out of 12 patients demonstrated greater than 50% hair regrowth as measured by Severity in
Alopecia Tool (SALT) scoring. Liu and colleagues performed a retrospective study which
consisted of patients age 18 years or older with AA with at least 40% scalp hair loss treated with
tofacitinib. The authors found that 77% achieved a clinical response, and 58% of patients had a
greater than 50% change in SALT score. There have been minimal adverse effects reported to date.
Moreover, these results are better than what has been reported for contact immunotherapy and
systemic steroids. Therefore, Xeljanz is likely to be more beneficial than other available standard
therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 62-year-old female enrollee has requested authorization and coverage for Xeljanz.A review of the record indicates that the enrollee has been diagnosed with alopecia areata. In an
undated letter, the provider reported that the enrollee has tried squaric acid, Rogaine, and
intralesional Kenalog injections.The Health Insurer indicates that the requested medication is investigational for the evaluation of
the enrolleeas medical condition. Therefore, the Health Insurer has denied coverage for the
requested medication. The physician reviewer found that Alopecia areata is an autoimmune medical condition that causes disfiguring patchy hair loss. This
patientas medical condition is severe. She has failed standard therapy with intralesional Kenalog,
squaric acid and Rogaine. Her provided has requested Xeljanz as the next most appropriate step in
therapy for her medical condition. This immunosuppressant medication is accepted medical
therapy for this autoimmune medical condition. Xeljanz is an immune-modulating therapy, which
has been approved by the U.S. Food and Drug Administration (FDA) for multiple immunemodulated
diseases, including rheumatoid arthritis, psoriatic arthritis, ulcerative colitis, and
juvenile rheumatoid arthritis. The safety and efficacy of Xeljanz in alopecia areata is welldescribed
in current literature. Since this patient has failed standard therapy, Xeljanz is the
appropriate next step in therapy. Therefore, Xeljanz is likely to be more beneficial than other
available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 62-year-old female enrollee has requested authorization and coverage for Xeljanz.A review of the record indicates that the enrollee has been diagnosed with alopecia areata. In an
undated letter, the provider reported that the enrollee has tried squaric acid, Rogaine, and
intralesional Kenalog injections.The Health Insurer indicates that the requested medication is investigational for the evaluation of
the enrolleeas medical condition. Therefore, the Health Insurer has denied coverage for the
requested medication. The physician reviewer found that the medical evidence supports the requested medication in this clinical setting. The records dated
10/30/20 documented 100% surface area of affected scalp. Her prior treatment included squaric
acid, Rogaine, and intralesional Kenalog injections. Per the records, this patient has failed typical
first-line and second-line therapies. Based on the medical literature, a JAK inhibitor would be the
next ideal choice for therapy. Therefore, Xeljanz is likely to be more beneficial than other available
standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 62-year-old female enrollee has requested reimbursement for the DecisionDx melanoma gene expression assay provided on 7/29/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that this patient presents with a melanoma with a Breslows depth of 3.65 mm. This places her into at least stage 2 disease. In stage 2 disease the National Comprehensive Cancer Network (NCCN) guidelines dictate certain protocols for further diagnosis, staging and prognosis as well as treatment paradigms. The melanoma DecisionDx testing would not change the staging, guidelines or care of this patient. Therefore, the DecisionDx testing performed on 7/29/15 was not 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 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 2

A 62-year-old female enrollee has requested reimbursement for the DecisionDx melanoma gene expression assay provided on 7/29/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that currently, the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx melanoma assay should be reserved for use only in a clinical trial setting. Peer-reviewed medical literature has not demonstrated that the DecisionDx melanoma assay changes treatment options or outcomes. Consequently, the DecisionDx melanoma gene expression assay provided on 7/29/15 was not 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 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 62-year-old female enrollee has requested reimbursement for the DecisionDx melanoma gene expression assay provided on 7/29/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC)) system that defines cutaneous melanoma stages 0-IV. While the majority of clinical stage I patients will be disease-free at five years, some stage I patients will develop advanced disease. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. DecisionDx melanoma assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class 1 consistent with a low risk of metastasis or Class 2 suggestive of a high risk of metastasis. One peer-reviewed publication indicated that there was a statistically significant association of a Class 1 signature by DecisionDx melanoma assay for primary dermal melanoma (PDM), whereas cutaneous metastatic melanoma (CMM) were more frequently class 2 (Sidiropoulos, et al). The authors concluded that the melanoma prognostic assay may be a useful tool for distinguishing PDM from CMM. According to the results of analysis of this patients melanoma performed with DecisionDx melanoma assay, the tumor was classified as Class 2 with molecular signature associated with a high risk of near term (within five years) metastatic disease. Identification of the increased risk of recurrence of melanoma in this patient helped establishing an appropriate follow-up plan. Thus, the DecisionDx melanoma gene expression assay provided on 7/29/15 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 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 


A 55-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees severe persistent asthma. The physician reviewer found that currently, the three initial trials of bronchial thermoplasty have demonstrated improved symptom control in well selected patients after the procedure was completed. Cox and colleagues reported on 112 patients with moderate to severe asthma and demonstrated improved control over the course of the one-year follow-up. Similarly, Pavord and colleagues found short-term worsening in symptoms, but evidence of improved long-term control of asthma. Castro and colleagues compared thermoplasty with a sham procedure and followed the patients for 12 months. The authors found that the thermoplasty group had fewer exacerbations and improved quality of life when compared to the sham group. However, this patients records do not indicate that she is likely to benefit from bronchial thermoplasty. The providers notes allude to a diagnosis of severe persistent asthma and normal pulmonary function testing (PFT). While PFT results may be unremarkable in patients with asthma, once the disease is persistent, the PFT results are often abnormal. Further, this patient is on medications for several illnesses which may mimic asthma, specifically reflux and sinus disease. Lastly, given the normal PFT findings, lack of clear asthma triggers along with persistent symptoms and chronic steroids, vocal cord dysfunction has not been ruled out, which is often confused for asthma and does not respond to bronchodilators, steroids or bronchial thermoplasty. All told, the requested bronchial thermoplasty is not supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested procedure is 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 

The parent of a 13-year-old male enrollee has requested authorization and coverage for Humatrope 24 mg cartridge. 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 the submitted documentation supports the requested medication in this clinical setting. This patient had a low annual growth velocity which indicated abnormal growth. His estimated adult height gradually declined to 66 inches, which indicates poor growth. His estimated adult height is below his genetic potential of 71.6 inches. Per the records, he failed growth hormone stimulation testing with a peak less than 10ng/mL, which indicates growth hormone deficiency in the setting of poor growth. Therefore, Humatrope 24 mg cartridge is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 51-year-old female enrollee has requested authorization and coverage for physical therapy. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees spiral fractures of left fourth and fifth metacarpals. The physician reviewer found that in the medical literature, Hagen and colleagues noted that, there is empirical evidence that exercise therapy (ET) has beneficial clinical effects for most musculoskeletal conditions (MSCs). This patient has undergone 60 sessions of physical therapy and is continuing her home exercise program. The provider reports that the patient has had forward progression in therapy, although it has been slow. While the patient is also performing a home exercise program, she has remaining deficits due to a muscular skeletal condition, which are affecting her activities of daily living. Moreover, the patient requires the services of a trained physical therapist at this time. Given these findings, the requested physical therapy is medically necessary. Based on the foregoing discussion, the requested services 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 


A 38-year-old female enrollee has requested reimbursement for substance use partial hospitalization program services provided from 8/22/16 through 8/26/16. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. The Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is a nationally accepted tool for determining the appropriate level of care. Based on LOCUS, partial hospitalization program services were not medically indicated.  This patient presented with a low risk of harm.  She had no current suicidal or homicidal ideation. She had passive suicidal thoughts, but no plan.  In terms of functional status, the records documented moderate impairment. Due to her substance use, she was not fulfilling her responsibilities. She was having interpersonal conflicts with her husband over her substance use. The records documented the significant comorbidity of her ongoing substance use despite negative consequences. The documentation noted a moderately stressful recovery environment. There were conflicts in the patients relationship with her husband over her current substance use. The patients husband takes Tramadol, which is a significant trigger for the patient as she has recently abused this drug. However, she has a supportive environment. Her husband was described as supportive. She has a good relationship with her children and her stepmother. The patient had a significant response to past treatment. She was sober for 15 years, which is a substantial period of time. The records documented that the patient accepted her illness and was engaged in her recovery. She attended groups and psychotherapy. Based on these factors, the patient met the criteria for an intensive outpatient program during the dates of service in dispute. Thus, substance use partial hospitalization program services provided from 8/22/16 through 8/26/16 were not medically necessary for the treatment of this patient. 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 


An 18-year-old male enrollee has requested reimbursement for mental health intensive outpatient program (IOP) services provided from 12/16/15 through 1/18/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the services at issue were medically necessary for treatment of the patients medical condition. The documentation submitted for review supports placement at the IOP level of care. Tamez and colleagues report on the benefits of treating depression in IOP programs particularly if the patient does not require acute hospitalization, but requires additional supportive services prior to fully reintegrating back into the community. In this case, the patient has a history of depression, OCD with prior suicide attempts one of which was serious as the only reason for its failing was the failure of the apparatus. Per the individual session note dated 1/8/16 the patient reported to being very depressed and feeling alone. During the dates in dispute the patient required continued supportive services with individual, family and group therapies prior to discharge into the community. Accordingly, IOP services provided from 12/16/15 through 1/18/16 were medically necessary for treatment of the patients behavioral health condition. Therefore, for the reasons stated above, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 61-year-old female enrollee has requested reimbursement for the in-office surgical injections performed on 8/4/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees lumbar spondylosis with arthropathy.   The physician reviewer found that lumbar medial branch blocks are not investigational and are standard of care for lumbar facet mediated pain. Lumbar facet blocks are indicated for DDD and facet mediated pain in the axial lumbar spine. There are a multitude of studies indicating reduced pain, improved function and better quality of life following these injections. All told, the in-office surgical injections performed on 8/4/15 were likely to have provided this patient with an improved health outcome as compared to standard available therapies. Based upon the information set forth above, the services at issue were 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 61-year-old female enrollee has requested reimbursement for the in-office surgical injections performed on 8/4/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees lumbar spondylosis with arthropathy.   The physician reviewer found that the available records document that this patient has mild facet arthropathy as demonstrated on magnetic resonance imaging (MRI) as well as having discogenic radiculopathy. However, the medial branch blocks performed on 8/4/15 are not indicated in the presence of another clear cause of the patients low back and radicular pain. Further, the use of repeated diagnostic blocks absent a plan for radiofrequency neurolysis is not consistent with clinical practice guidelines. Thus, the in-office surgical injections performed on 8/4/15 were 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 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 61-year-old female enrollee has requested reimbursement for the in-office surgical injections performed on 8/4/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees lumbar spondylosis with arthropathy.   The physician reviewer found that in the documentation available for review, there is a lack of radiographic evidence of facet arthropathy at the L5-S1 location. In addition, it is unclear why the procedure was performed with steroids. The current peer-reviewed medical literature requires medial branch blocks to be performed using either solely lidocaine or bupivacaine and require a pain diary for the day to verify when the local anesthetic wore off for medial branch blocks (Manchikanti, et al). Further, these injections are not to be performed when patients have significant radicular pain. Finally, there is a lack of documentation of a home exercise program, physical therapy or other conservative, non-invasive and non-pharmacological, treatment options. Thus, the in-office surgical injections provided on 8/4/15 were 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 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.