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

Summary Reviewer 2


A 24-year-old female enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that the Health Insurer has denied this request as investigational indicating medical studies do not show that IMRT works as well as or better than other types of treatment. There are emerging data for the use of IMRT for Hodgkins lymphoma (Chera, et al). The rationale to use IMRT includes relative sparing of the lungs, heart, salivary glands, breast and other tissues. Reducing the mean cardiac dose is particularly clinically relevant in a patient expected to have a long term survival, particularly if cardiotoxic drugs were used, such as is in this case. Hodgkin lymphoma fields have historically been much more comprehensive in terms of volume. For this patient, clinically significant reductions in dose-volume measures with IMRT are seen in the mean heart dose; left breast, and esophageal dose exposure is also reduced with IMRT. In younger patients, IMRT is used to spare breast tissue, in order to reduce subsequent breast cancer risks. In sum, IMRT is indicated for this patient and there is sufficient support provided showing a plausible, clinically meaningful benefit in this patient. Given the support above, IMRT 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 services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 24-year-old female enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that the goal for the treatment of Hodgkins disease in young adults is to eradicate the disease to minimize the risks of late effects secondary to therapy. The late effects of treatment have become more apparent with increased survival of Hodgkins patients. IMRT is superior to three-dimensional conformal radiation therapy (3D-CRT) for patients with bulky mediastinal disease. This is because IMRT allows a more conformal dose of radiation to mediastinal disease while at the same time delivering a lower dose to adjacent sensitive organs such as heart and lungs. The National Comprehensive Cancer Network (NCCN) Hodgkins lymphoma guidelines state Advanced radiation therapy (RT) technologies such as IMRT, breath hold or respiratory gating, image guided RT or proton therapy may offer significant and clinically relevant advantages in specific instances to spare important [organs at risk] OAR such as the heart (including coronary arteries, valves and left ventricles), and decrease the risk for late normal tissue damage while still achieving the primary goal of local tumor control. In this case, IMRT will be more beneficial treatment to avoid long-term complications in this young patient who has a very high chance of cure. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 45-year-old male enrollee has requested reimbursement for inpatient admission at a non-participating facility from 11/13/16 through 11/14/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees acute appendicitis. The physician reviewer found that the inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. Outpatient observation admission is appropriate when the physician is unsure about the patients need for inpatient admission and requires time for short term treatment, assessment, and reassessment in order to make that decision or the physician anticipates that the patients condition can be evaluated/treated within 24 hours and/or rapid improvement of the patients condition can be anticipated within 24 hours. In this patients case, he was admitted in stable condition and could have been treated at an observational level of care. He had a laparoscopic appendectomy without any complications.  This procedure does not have to be performed on an inpatient only basis. Pain control was adequate after the surgery, and the patient tolerated an oral diet. The submitted documentation demonstrates that this patient could have been treated at a lower level of care. As such, admission at a non-participating facility from 11/13/16 through 11/14/16 were not medically necessary for treatment of the patients medical condition. 
Therefore, for the reasons stated above, 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 five-year-old male enrollee has requested reimbursement for gene testing performed on 11/20/15. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees generalized epilepsy of unknown etiology. The physician reviewer found the clinical utility of CMA is well established in the peer-reviewed literature and is considered first-line genetic tests for individuals with developmental delays and autism spectrum disorders according to the American Academy of Pediatrics (AAP) and the American College of Medical Genetics (ACMG) (Schaefer, et al; Moeschler, et al).  Olson and colleagues evaluated the role of copy number variation (CNV) abnormalities detectable using CMA testing in patients with epilepsy. The authors found that in at least 40 cases (5%), the epilepsy phenotype was explained by a CNV, including 29 patients with epilepsy-associated syndromes and 11 with likely disease-associated CNVs involving epilepsy genes or hotspots. Copy number abnormalities were found to play an important role in patients with epilepsy. The authors concluded that because the diagnostic yield of CMA for epilepsy patients is similar to the yield in autism spectrum disorders and in prenatal diagnosis, for which published guidelines recommend testing with CMA, we recommend the implementation of CMA in the evaluation of unexplained epilepsy. Similarly, Striano and colleagues compared 279 patients with unexplained epilepsy to patients with non-syndrome intellectual disability and healthy controls using CMA. The authors found that patients with epilepsy show a significantly increased burden of large, rare, gene-rich CNVs. Several specific (ion channel) genes were noted to have a specific association between the identified CNVs and epilepsy (Striano, et al). Moreover, CMA has been shown to provide clinically actionable information with results influencing medical care by precipitating medical referrals, diagnostic imaging, and specific laboratory testing (Coulter, et al). For the reasons provided, the gene testing performed on 11/20/15 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

The parent of a five-year-old male enrollee has requested reimbursement for gene testing performed on 11/20/15. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees generalized epilepsy of unknown etiology. The physician reviewer found the gene testing performed on 11/20/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. CMA has become standard of care to evaluate children with developmental delay, intellectual disability, autism spectrum disorders or congenital anomalies. Seven percent of microarray results impact clinical management, a rate which is similar to other genetic tests (Riggs, et al). Olson and colleagues found that at least 5% of individuals with epilepsy had pathogenic copy number variants. In sum, data have emerged showing that actionable findings from chromosomal microarray justify its use. All told, the testing at issue 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 3

The parent of a five-year-old male enrollee has requested reimbursement for gene testing performed on 11/20/15. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees generalized epilepsy of unknown etiology. The physician reviewer found that ezugha and colleagues studied 82 children with developmental delay or seizures. The study found abnormalities on CMA in 20 children (23.5%), but found the highest yield on CMA in those with four or more additional clinical variables, including seizures, hypotonia, learning delay, hypotonia, dysmorphic features, developmental delay, or autism. In children with three or fewer of these variables, like this patient who has no additional variables besides epilepsy, the yield of CMA was 8.7%. Given that this patient does not have heath concerns outside of seizures, the likelihood of abnormal finding on CMA is likely to be low. In addition, CMA is recommended as standard of care in children with intellectual or developmental disability or multiple congenital anomalies. This patient does not meet these criteria. As such, the gene testing performed on 11/20/15 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 




A 51-year-old female enrollee has requested authorization and coverage for Pazeo (olopatadine hydrochloride ophthalmic solution 0.7%) eye drops. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees eye condition The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. This patient has significant dry eye and chronic allergic conjunctivitis. Per the provider and noted by the patient, she has tried several of the over the counter medications without success or improvement of her symptoms. This patient has also been prescribed Pataday drops but those eye drops were also ineffective. The records indicate that this patient has tried and failed standard treatments. All told, Pazeo (olopatadine hydrochloride ophthalmic solution 0.7%) eye drops for treatment of this patients eye condition is medically necessary. Therefore, based on the reasons stated above, 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 1

A 52-year-old female enrollee has requested reimbursement for gene testing (unlisted multianalyte assay with algorithmic analysis) performed on 12/21/18. 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 prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has been thought to add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Berger reported on 156 cases, but there was not sufficient follow-up to determine the real value of the assay. It is not known how the five-year DecisionDx-Melanoma testing data compares to the ten-year Balch data. Most importantly, it is not clear if DecisionDx-Melanoma testing can be used to make clinical decisions about treatment. Therefore, gene testing (unlisted multianalyte assay with algorithmic analysis) performed on 12/21/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 52-year-old female enrollee has requested reimbursement for gene testing (unlisted multianalyte assay with algorithmic analysis) performed on 12/21/18. 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 this patient has an early stage melanoma. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. 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. All told, gene testing (unlisted multianalyte assay with algorithmic analysis) performed on 12/21/18 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 52-year-old female enrollee has requested reimbursement for gene testing (unlisted multianalyte assay with algorithmic analysis) performed on 12/21/18. 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 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. Thus, gene testing (unlisted multianalyte assay with algorithmic analysis) performed on 12/21/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The patient is a 59-year-old male with a history of prior bilateral renal oncocytomas.  The patient has requested reimbursement for cryoablation for kidney mass performed on 11/06/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. The patient had a renal tumor (oncocytomas) that was a stage T1 lesion. The patient declined active surveillance. The patient was not an appropriate surgical candidate for nephrectomy or partial nephrectomy, given the history of recurrent oncocytomas. The tumor was not an angiomyolipoma. Radiofrequency cryoablation of the renal tumor is supported in this clinical scenario. The medical literature has demonstrated renal cryoablation to have similar or improved outcomes compared with nephrectomy. The studies consistently showed a lower decline in glomerular filtration rate with renal cryoablation. Therefore, cryoablation of the renal mass on 11/06/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 59-year-old female who was admitted to residential treatment for worsening depressive symptoms on 1/05/20. At the time, she endorsed low mood as well as many neurovegetative impairments, including increased sleep, decreased energy and anhedonia. The physician reviewer found that based on the limited information noted above, the patient does not meet medical necessity criteria for residential treatment. There is no evidence of suicidality. There is no evidence of functional decline. There was no evidence of psychosis or disorganization.
The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.
In terms of risk of harm, the records support a score of 2. She had a low risk of harm given lack of suicidality or self-injurious behaviors.
With regard to functional status, the records support a score of 3. The patient reported that she had not had employment for over a year.
In terms of comorbidity, the records support a score of 4. She has major medical comorbidity, including history of head trauma/closed head injury as well as stage IV vaginal cancer.
With regard to level of stress of the recovery environment, the records support a score of 2. Her recovery environment is minimally stressful based on the information provided. She reported a close relationship with her daughter.
In terms of level of support of the recovery environment, the records support a score of 2. The documentation noted that the patient had a psychiatrist and therapist.
With regard to resilience and treatment history, the records support a score of 3. She has seen may providers, without complete remission of her symptoms.
In terms of engagement and recovery, the records support a score of 2. The patient has been adherent with treatment plan, including medication.
Thus, her composite score is 18. Based on LOCUS criteria, she did not meet criteria for residential treatment level of care. Therefore, residential treatment provided from 1/05/20 through 1/09/20 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 55-year-old male enrollee has requested reimbursement for CPT code 81479 provided on 12/21/18. 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 currently are three major approaches to the management of localized prostate cancer. These include surgical prostatectomy, radiation therapy, or active surveillance with no specific treatment given. Recommendations as to these options are based on risk stratification, which is a process that takes into account patient factors, prostate-specific antigen level, clinical stage, Gleason grade, and the percent of involvement of the cores. Using this methodology, this patient falls into the very low risk category. Generally, active surveillance is recommended for such patients. Oncotype DX testing is an analysis of the expression of 12 genes in an individuals cancer cells. It then classifies that cancer into various risk categories of cancer progression. Such analyses appear useful in patients undergoing prostatectomy and in other risk categories. However, there is a lack of support for the use of this testing in patients in the very low risk category, such as this patient. Therefore, CPT code 81479 provided on 12/21/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 55-year-old male enrollee has requested reimbursement for CPT code 81479 provided on 12/21/18. 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 sufficient support for the services at issue in this clinical setting. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy, and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays. It is considered a standard of care in guiding treatment decision making. This patient with low risk disease meets criteria for testing. In sum, CPT code 81479 provided on 12/21/18 was likely to have been more beneficial than other methods of evaluating this patient.