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

Summary Reviewer 


The parent of a 14-year-old male enrollee has requested reimbursement and prospective authorization and coverage for residential treatment program services provided from 1/21/16 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 the submitted documentation supports the medical necessity of the services at issue.  The treatment record indicates that this patient has severe, chronic difficulties that have recently presented significant difficulty both for him, his family and those around him. This patient is receiving a fairly high level of therapeutic interventions and is responding positively to these interventions.  The treatment plan and psychiatric note document that the patient is improving and benefiting from his treatment. However, he still has significant problems and continues to require intensive treatment at the residential level of care.  This patient has a history of repeated aggression that has the potential to cause serious injury to others, and he has potential for serious risk of harm to his family if he were not removed from home during his treatment.  All told, residential treatment program services provided from 1/21/16 forward were and are medically indicated for the treatment of this patient.  Therefore, the requested 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 Overturned

Summary Reviewer 


A 66-year-old female enrollee has requested authorization and coverage for Lantus. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees diabetes. The physician reviewer found that there is sufficient support in the medical literature for the requested medication in this clinical setting. The patient was placed on Levemir and Basaglar to control her diabetes. She had side effects and failure to respond properly to Levemir and Basaglar. The alternative Levemir insulin and the biosimilar insulin Basaglar did not provide her with similar benefit to Lantus and were associated to poor control. It is important to note that Lantus is not interchangeable with Levemir. Levemir is a different insulin analog and has a different pharmacokinetic profile. Usually, patients on Levemir require twice a day dose and larger doses, to mimic the effect of Lantus (Wallace, et al). The patient tried Levemir and Basaglar with poor response.  In this patients case, the alternative insulins were not effective in managing her diabetes. The patient was well controlled on Lantus. Accordingly, treatment with Lantus has been demonstrated as medically necessary. 

Therefore, as stated above, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 58-year-old male enrollee has requested authorization and coverage for right shoulder surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. The patient has a history of right shoulder pain associated with an isolated SLAP tear. Non-operative treatment has been tried and failed. The provider is requesting arthroscopy and biceps tenodesis. Cvetanovich and colleagues performed a retrospective query from years 2007 to 2016 for the management of isolated SLAP tears. The treatments compared included debridement, SLAP repair, open or arthroscopic biceps tenodesis, and SLAP repair combined with biceps tenodesis. The analysis revealed that surgical treatment of isolated SLAP tears in the United States has shifted from 2007 to 2016, with an increase in the frequency of biceps tenodesis and decrease in the frequency of SLAP repair, particularly in patients older than 40 years. A review of the surgical results indicates that biceps tenotomy or tenodesis yields good results in this age group. The article by Fourman and colleagues noted that surgical repair of type VIII SLAP tears in the young athletes led to significant improvements in stability, pain, range of motion, and outcome scores at midterm follow-up, except in throwers in whom the results were not as good. These findings suggest that type VIII SLAP tears should be repaired in young athletes because outcomes do improve. However, in this patients age group, biceps tenotomy or tenodesis remains the procedure of choice. Therefore, the requested right shoulder surgery is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 68-year-old female enrollee has requested authorization and coverage for Glumetza. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees type 2 diabetes. The physician reviewer found the request for Glumetza is medically necessary for treatment of the patients medical condition. According to the American Diabetes Association guidelines, metformin is first line of therapy in patients with diabetes type 2. It also should be a component of combination therapy as step-up therapy is prescribed. The most common side effect to intermediate release metformin is gastrointestinal (GI) intolerance, therefore several preparations are available (Jabbour and Ziring). In this case, the patient had adverse reaction to generic metformin and has been able to tolerate the brand Glumetza. Glumetza utilizes a modified delivery system, polymer-based, oral drug delivery systems, which allow delivery of metformin hydrochloride to the upper GI tract. There is no generic form of Glumetza. In the aqueous GI environment, the dosage form swells remarkably thereby increasing in size and geometry from where drug is released slowly by a process of diffusion through the gel matrix that is independent of pH. Even though the active component is the same, the delivery systems differ, and therefore it is likely that the patient had an adverse reaction to the generic delivery systems. It is therefore medically necessary that this patient continue taking Glumetza as part of her diabetes management. Therefore, the requested medication is 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 3


A 49-year-old female enrollee has requested reimbursement for the Anser ADA testing performed on 1/11/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that the records indicate this patient was on Humira but appeared to be non-responsive. Determining therapeutic levels with the Anser ADA test with no antibodies can provide a valuable medical guide to the treating provider. As noted in the medical literature, the Anser ADA test measures the Humira blood level and detects antibodies to Humira (Ordas, et al). A patient with detectable levels and no antibodies will likely require a change in treatment management in order to control their disease, as the test potentially implies an escape phenomenon to Humira (Afif, et al). Patients with undetectable levels and low/no antibodies are under-dosed and a higher dose will be needed to achieve remission and control of disease (Baert, et al). Patients with a low level and detectable antibodies have a low drug level due to the development of antibodies. In this case, the patient was found to have detectable levels and no antibodies and was switched to Remicade. In this clinical setting, the use of the Anser ADA test performed on 1/11/16 was likely to have been more beneficial for evaluation and treatment of this patients Crohns disease than standard available testing. 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 59-year-old female enrollee has requested reimbursement for Foundation One CDX testing performed on 11/23/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing prognostic information, the value of next generation sequencing to predict candidates for specific mutation-driven treatment holds promise, but is not yet ready for routine clinical use. Although the ability to decipher genomic aberrations in individual breast cancers to the single nucleotide resolution is now possible, there is a lack of data to show that this information can guide treatment decisions for patients with metastatic breast cancer. The use of next generation sequencing, such as with FoundationOne CDx testing, continues to be the subject of ongoing clinical trials. Therefore, FoundationOne CDx performed on 11/23/18 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 34-year-old female enrollee has requested reimbursement for acute inpatient mental health treatment for adults provided form 3/08/19 through 3/12/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation. With regards to functional status, the records support a score of 2 due to overall good daily functioning while on the inpatient unit with recent resolution of self-care difficulties. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to no recent history of substance use and resolution of any possible medical issues that contributed to her initial admission presentation. With regards to level of stress of the recovery environment, the records support a score of 2 due to some issues on an intermittent basis with interpersonal conflict due to her psychiatric issues. In terms of level of support of the recovery environment, the records support a score of 2 due to supportive resources and professional supports. With regards to treatment and recovery history, the records support a score of 2 due to rapid resolution of acute symptoms. In terms of engagement and recovery status, the records support a score of 2 due to good cooperation in treatment and noted insight into the need for treatment. Therefore, the patient has a composite score of 13. According to the LOCUS, a score of 28 or greater is required for medically managed inpatient care. Therefore, acute inpatient mental health treatment for adults provided from 3/08/19 through 3/12/19 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 62-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 7/25/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. The physician reviewer found that molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. National Comprehensive Cancer Network guidelines strongly advise broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. National Comprehensive Cancer Network guidelines supports the use of liquid molecular profiling, such as Guardant360, if there is insufficient tissue for molecular analysis and follow-up tissue-based analysis will be done if an oncogenic driver is not identified. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. In this case, the records noted that tissue-based molecular testing was not feasible, as it was limited by tissue of insufficient quantity. Therefore, Guardant360 testing performed on 7/25/20 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 62-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 7/25/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. The physician reviewer found that adenocarcinoma of the lung should be evaluated for specific molecular and mutational targets, such as EGFR. ALK, ROS-1, and PDL-1 positivity. Each of these has a therapeutic implication. Usually, these are analyzed from the tissue biopsy specimen, although plasma assay does appear to be a reasonable substitute when tissue biopsy is not possible or safe. Even beyond that issue, in lung cancer, there is some data to indicate that plasma assay may actually be superior to tissue. Agarwal studied this issue in 323 patients, many of whom had both types of assays, but many only had the serum assay. It was noted that 33% of those who had only the serum assay had a targetable mutation, and 86% of these experienced a clinical response to treatment. Only 21% of those who had tissue assay alone had such a targetable situation. There is sufficient support for the services at issue in this clinical setting. Therefore, Guardant360 testing performed on 7/25/20 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 62-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 7/25/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. The physician reviewer found that the therapy of advanced non-small cell lung cancer (NSCLC) has been revolutionized by the finding of EGFR mutations in adenocarcinomas. Even if stage IV disease is present, therapy targeted to EGFR with erlotinib results in prolonged survival when compared with standard chemotherapy regimen. The mutational landscape of NSCLC has significantly expanded to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. Thus, mutational analysis on its own is clinically indicated in these cases of NSCLC. Plasma cell free/circulating tumor DNA testing is indicated if the primary tumor is inaccessible. According to the National Comprehensive Cancer Network guidelines, In the initial diagnostic setting, if following pathologic confirmation of NSCLC diagnosis there is insufficient material for molecular analysis, cell free/circulating tumor DNA should be used only if follow-up tissue based analysis is planned for all patients in which an oncogenic driver is not identified. In this case, insufficient material was available after the biopsy. The medical evidence supports the services at issue in this patients case. Therefore, Guardant360 testing performed on 7/25/20 was likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 62-year-old male enrollee has requested reimbursement for ICU level of care provided on 7/15/18 and intermediate level of care provided from 7/16/18 through 7/20/18. 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 this patient's ICU admission on 7/15/18 was medically necessary. Specifically, this patient had a left neck blood vessel exploration with muscle flap. The standard of care for this procedure is ICU admission postoperatively due to the high risk for airway compromise related to neck swelling or hematoma after exploration and flap coverage. Failure to treat could result in loss of the airway with acute respiratory failure and need for mechanical ventilation. As such, the ICU level of care was medically necessary and appropriate postoperatively for the first 24 hours after surgery. After the initial 24 hours following surgery, the patient was noted to be clinically stable, with a viable flap and no evidence of airway compromise. In this setting, admission to the intermediate care floor was clinically appropriate and consistent with the standard of care due to need for frequent flap monitoring. Furthermore, this patient had an unstable medical comorbidity of acute postoperative atrial fibrillation that occurred after surgery. Due to the acuity of the patient, with need for frequent monitoring, nasoenteric tube care and atrial fibrillation monitoring, the intermediate level of care was medically indicated. In sum, the ICU level of care provided on 7/15/18 and intermediate level of care provided from 7/16/18 through 7/20/18 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 24-year-old male who has been diagnosed with ilieocolonic Crohnas disease. He has failed azathioprine. The patient has requested authorization and coverage for Humira Pen (adalimumab pen-injector kit 40 mg/0.4 ml) for a weekly dosage. The Health Insurer has denied this request and reported that the requested medication regimen is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination.  The physician reviewer found that the requested medication regimen is medically necessary based on the provided documentation. Anti-tumor necrosis factor (TNF) medications such as Humira are recommended by current guidelines for Crohnas disease in patients with moderate-to-severe disease. The use of Humira 40 mg more frequently than every 14 days can be supported to prevent disease complications. In the CLASSIC-II trial, 60 of 204 open-label patients required an increase in dosing to every week. Additionally, American College of Gastroenterology guidelines for the treatment of Crohnas disease state, aThose with continued symptoms shouldahave their medication dose adjusted in order to attempt to optimize therapy.a In this case, the patient had disease previously controlled on Humira 40 mg every seven days, then active disease (corroborated by imaging) requiring when decreased to Humira 40 mg every 14 days, and then recovery of remission when increased back to Humira 40 mg every seven days. Therefore, a decrease to Humira 40 mg every 14 days, or a discontinuation of Humira (even if another alternative is immediately attempted), could result in complications of disease activity, such as disease flare, fistula, need for surgery, hospitalization, or colonic dysplasia leading to colorectal cancer. Therefore, Humira Pen (adalimumab pen-injector kit 40 mg/0.4 ml) for a weekly dosage is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 48-year-old female enrollee has requested reimbursement for the lab testing provided on 11/28/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees migraines, mild memory impairment, and prior syncope. The physician reviewer found that there is a lack of conclusive evidence of a linkage between migraines and homocysteine levels (Lippi, et al). Further, the current guidelines from the American Heart Association and American Stroke Association do not support the performance of this testing (Goldstein, et al). In addition, the current practice guidelines from the American College of Medical Genetics (ACMG) do not support the performance of testing for MTHFR (Hickey, et al). With regard to Factor V Leiden, Grody and colleagues report that the ACMG does not recommend random screening of the general population for factor V Leiden. Routine testing is also not recommended for patients with a personal or family history of arterial thrombotic disorders (e.g., acute coronary syndromes or stroke) except for the special situation of myocardial infarction in young female smokers. In this case, there was no reported family history noted of a hypercoagulable condition. Nor does the patient have a history of a thrombus or other similar condition. Given that the patient did not present with a condition related to a coagulable disorder the need for testing for Factor V Leiden is not supported in the records provided for review. All told, the lab testing provided on 11/28/16 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.