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

Summary Reviewer 

A 58-year-old female enrollee has requested authorization and coverage for breast magnetic resonance imaging (MRI). The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollee, who is status post breast implant placement. The physician reviewer found that according to the American College of Radiology appropriateness criteria, in a patient with average risk for breast cancer, or less than 15% lifetime risk, mammography or breast tomosynthesis is the appropriate screening examination regardless of the presence of breast implants. In the absence of additional risk factors, MRI is not indicated in this setting. There are specific mammographic techniques that are utilized, such as the Eklund maneuver, to displace the implant away from the breast tissue during mammography for better visualization of the breast tissue. If implant rupture is a concern, then non-contrast MRI would be indicated to evaluate for implant integrity. Alternatively, if the patient has implant rupture with free silicone in the breast, this could obscure findings on mammography, and contrast enhanced MRI may be indicated. However, there is no indication of either of these scenarios in the clinical records. In this case, breast MRI is not indicated for breast cancer screening. Specialized techniques exist for mammographic visualization of the breast tissue in the augmented breast. Thus, the requested breast MRI is not medically necessary for the evaluation of this patient. Therefore, the requested services are not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 




The parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment provided from 6/16/16 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 behavioral health condition The physician reviewer found that the residential treatment provided from 6/16/16 forward was not and is not medically necessary for treatment of the patients medical condition. Per the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient qualifies for Level Four, intensive integrated services without 24-hour psychiatric monitoring. Specifically, this level of care would include placements such as group homes or foster care. This level qualifies him for treatment by a child psychiatrist and nurse as well as individual and family therapy. Support services should also be provided. Specifically, in Dimension I, risk of harm, he scores as some risk of harm. Dimension II, functional status, he qualifies as serious functional impairment. Dimension III, co-morbidity developmental, medical, substance use and psychiatric, he qualifies as major co-morbidity. In Dimension IV, recovery environment, he scores as minimally stressful environment as his material needs are met without significant cause for concern. He also has a highly supportive environment, as the documentation notes he has access to a private school, tutors, and therapists. In Dimension V, resiliency and treatment history, he has shown poor resiliency and poor response to treatment. In Dimension VI, treatment acceptance and engagement, he has shown an obstructive engagement, as he was ambivalent, avoidant or distrustful in his relationship with clinicians and other care providers. However, his parents showed an optimal acceptance and engagement in his treatment. Given the above, the RTC level of care as of 6/16/16 was not and is not medically necessary for treatment of the patients medical condition.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 52-year-old male enrollee has requested reimbursement for optical endomicroscopy performed on 5/30/18. 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 Confocal laser endomicroscopy (CLE) is based upon the principle of illuminating a tissue with a low-power laser and then detecting fluorescent light reflected from the tissue. The laser is focused at a specific depth, and only light reflected back from that plane is refocused and able to pass through the pinhole confocal aperture. As a result, scattered light from above and below the plane of interest is not detected, increasing spacial resolution. The area being examined is scanned in the horizontal and vertical planes, and an image is reconstructed. In this manner, microscopic imaging of biological tissue in vivo is possible due to the high lateral resolution of confocal imaging. Since CLE relies upon tissue fluorescence, intravenous and/or topically applied contrast agents are required. The current medical evidence has not demonstrated the superior efficacy of the services at issue in this clinical setting. At this time, the standard of care is to base management decisions on actual biopsy specimens. Therefore, optical endomicroscopy performed on 5/30/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 52-year-old male enrollee has requested reimbursement for optical endomicroscopy performed on 5/30/18. 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 some support for the services at issue in this clinical setting. Eluri and colleagues noted confocal laser endomicroscopy (CLE) can increase the yield of dysplasia detection with good accuracy compared with random biopsies. Wang and colleagues noted the use of CLE as a complementary tool during the endoscopic evaluation of Barretts esophagus was strongly supported by the panelists.  In this case, the finding of nodule with dysplasia warranted resection rather than ablation as performed for the remaining Barretts esophagus. For these reasons, optical endomicroscopy performed on 5/30/18 was likely to have been superior over other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 52-year-old male enrollee has requested reimbursement for optical endomicroscopy performed on 5/30/18. 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 superior effectiveness of the services at issue has not been established. The American Society for Gastrointestinal Endoscopy (ASGE) noted that confocal laser endomicroscopy (CLE) is an emerging technology that has the potential to significantly reduce the number of biopsies in Barretts esophagus and inflammatory bowel disease and reduce the need for removal of non-neoplastic colorectal polyps compared with while light endoscopyLimitations of CLE include the high cost of the equipment and probes, the lack of proven efficacy compared with other widely available advanced imaging techniques, and the need for either intravenous or topical fluorescent contrast agents. Before the technology can be widely accepted, many further studies are needed to determine its clinical efficacy and evaluate its cost-effectiveness and its utilization in both academic and community settings. Intravenous fluorescein used to highlight the vasculature, lamina propria, and intracellular spaces of this tissue being examined does not stain cell nuclei. Nuclear staining can be achieved using topical contrast agents such as acriflavine and cresyl violet, but there is concern over mutagenic potential with the topical agents. In this case, the services at issue were not likely to have been of greater benefit than post-treatment histology and/or follow-up endoscopy to assess for residual dysplastic Barretts tissue. Thus, optical endomicroscopy performed on 5/30/18 was not likely to have been more efficacious than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 43-year-old male who was diagnosed at age 41 with adenocarcinoma of the prostate. The patient has requested authorization and coverage for positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging, skull based to mid-thigh. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient. The physician reviewer found that following radical prostatectomy, it is expected that PSA levels should become non-detectable.  When they remain elevated, it is an indication that there is still functioning prostatic tissue or metastatic disease. The National Comprehensive Cancer Network (NCCN) recommends following PSA levels, and when PSA levels increase on two successive assays, considering imaging, such as chest x-rays, bone scans, CT, magnetic resonance imaging (MRI), and PET scans. Prostate bed biopsy is also a consideration. One problem is the lack of accuracy of the various imaging modalities when the post-radical prostatectomy PSA levels are low, but rising. These patients generally will have a recurrence, but it will often be undetectable with conventional imaging modalities. Bone scans will be rarely positive in patients with PSA levels less than 10. Plain x-rays will generally not detect a lesion until 50% of the bone mineralization is lost or gained (sclerotic metastases). CT scans and MRI are dependent on the site scanned, and will only pick up gross anatomic distortions or disease.  Microscopic or small lesions will be very difficult to detect. In order to effectively cover the areas detectable by PET scanning, one would have to perform CT or MRI scans of the head, neck, chest, abdomen, and pelvis. The value of PET scanning, especially when combined with CT scans, is that it depends on metabolic changes to detect abnormalities. Once recurrence is identified and localized, targeted therapy such as radiation can be utilized. There is sufficient support for the requested services in this clinical setting. Based on this patients rising PSA levels, and especially considering his young age, aggressive evaluation is warranted. Therefore, the requested PET with concurrently acquired CT for attenuation correction and anatomical localization imaging, skull based to mid-thigh is medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 52-year-old female enrollee has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there are insufficient high quality clinical outcomes reported to allow one to make definitive conclusions regarding the relative safety and efficacy of proton beam radiation for the management of this patients esophageal cancer, as compared to standard of care photon-based radiotherapy.  The American Society for Radiation Oncology (ASTRO) Model Policy for proton radiation does not support its use for thoracic malignancies (including esophageal cancer) outside the setting of a clinical trial. Proton beam radiation has the potential to reduce lower dose radiation exposure to surrounding normal tissues, but it remains to be seen as to whether such reduction in low dose is associated with clinically meaningful improvements in outcomes. Therefore, proton beam therapy is not likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 52-year-old female enrollee has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that currently, there is a lack of strong prospective clinical data in the medical literature to suggest that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for esophageal tumors. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy (IMRT). The comparison dosimetry was reviewed, and the major dose metrics for the normal structures are being met with the standard photon plan. Consensus group guidelines do not support the use of proton beam therapy in this setting. Also, there is a lack of level I evidence to support the use of proton beam therapy for the treatment of esophageal cancer. Thus, proton beam therapy is not likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 52-year-old female enrollee has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that proton therapy is well-established in dosimetric superiority and precision over photon therapy due to its Bragg peak. However, this dosimetric benefit does not always translate into a clinical benefit. An example of this lack of benefit is with prostate cancer, where proton therapy has the same rate of side effect as photon therapy. This is because the local organs at risk (bladder and rectum) have a high dose tolerance to radiation. This is not true for esophageal cancer, where the lung is very sensitive to radiotherapy. The decision on the benefit of proton radiotherapy for esophageal cancer should be made on a case-by-case basis. In this patients case, the treating provider submitted a comparison plan between photon radiotherapy and proton radiotherapy. Specifically, it was demonstrated that there was a V5 of 100% in the photon plan compared to less than 20% with the proton plan. The study by Allen and colleagues indicated that a V5 of greater than 90% is associated with a 46% rate of fatal radiation pneumonitis. Thus, proton beam therapy is likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 31-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/18/19. 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 this patient has an early stage melanoma. Commercially available gene expression profiling (GEP) tests are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear whether these tests provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariable 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. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Therefore, DecisionDx-Melanoma testing performed on 12/18/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 31-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/18/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index is thought to add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in that particular melanoma. It then classifies that melanoma based on the five-year risk of metastasis. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is unknown if DecisionDx-Melanoma can be used to make clinical decisions. Thus, DecisionDx-Melanoma testing performed on 12/18/19 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 31-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/18/19. 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. All told, DecisionDx-Melanoma testing performed on 12/18/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The parent of a 15-year-old female enrollee has requested reimbursement for residential mental health treatment for children and adolescents provided from 1/29/18 through 12/05/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining necessary level of care for children. With regards to risk of harm, the records support a score of 2. The patient not actively suicidal, but she had a history of suicidal ideation. In terms of functional status, the records support a score of 2. The patient had some issues with level of function due to chronic mental illness, but overall showed appropriate daily functioning including school progress in treatment and prior to treatment at the residential treatment center. In terms of comorbidity, the records support a score of 1. The patient did not have active medical problems and did not have a recent history of substance use. In terms of level of stress of the recovery environment, the records support a score of 2. The progress notes document that her relationship and family sessions were productive and were not adversarial. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents are involved in treatment on a regular basis and appeared to understand her needs. In terms of resiliency and treatment history, the records support a score of 3. It appears that the patient had response to her stay in the residential treatment center prior to her readmission for the disputed dates of service. She was participating in therapy programming and was not displaying seriously disruptive behaviors on a regular basis. It was noted that she had intermittent behavioral issues, but these were infrequent in nature. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy actively. In terms of acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 16. This score correlated with outpatient services. In sum, residential mental health treatment for children and adolescents provided from 1/29/18 through 12/05/18 was 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


The parent of a four-year-old male enrollee has requested reimbursement for FirstStepDx Plus dated 5/12/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees autism spectrum disorder. The physician reviewer found that battaglia and colleagues performed a study to demonstrate the usefulness of CMA in detecting the etiology of unexplained autism spectrum disorders associated with dysmorphic features in a large cohort of pediatric patients. The authors concluded that their study confirmed the value of CMA as the first-tier tool in the assessment of those conditions in the pediatric setting. Autism comprises a clinically heterogeneous group of disorders that share common features of impaired social relationships, impaired language and communication, and repetitive behaviors or a narrow range of interests. Autism can be considered complex in the presence of dysmorphic features and/or microcephaly or essential, such as in the absence of physical abnormalities and microcephaly. This patient is non-dysmorphic and would qualify for a designation of essential autism. The American Academy of Pediatrics recommends that any child with unexplained global developmental delay or speech/language delay be tested for Fragile X syndrome. Given the support in the peer-reviewed literature, FirstStepDx Plus performed on 5/12/16 has been established as 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.