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

Summary Reviewer 1

A 20-year-old male enrollee has requested authorization and coverage for inpatient admission for lidocaine infusions for seven days. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees orthostatic headache. The physician reviewer found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. This patient presents with new onset of daily headache with a positional component that has been extensively and appropriately evaluated. He has had aggressive therapy, including a blood patch, given the positional component and strong suspicion for idiopathic intracranial hypotension. Subsequently the diagnosis has been changed to chronic migraine. The issue in this case is the proper characterization of the patients headache disorder. His headache has features of intracranial hypotension due to the significant postural component, features of new daily persistent headache due to the clear onset and near constant nature of the headache, as well as chronic migraine. However, the therapy for all of these headache disorders is different. Intravenous lidocaine has a long history of use, but with minimal support in the peer-reviewed literature. For the patients current diagnosis of chronic migraine, treatment with Botox has an excellent track record in refractory patients. In addition, topiramate and Depakote are two other therapies that are commonly used in chronic migraine, and have double blind placebo controlled studies to support their efficacy. In this clinical setting, treatment with Botox with one of the anticonvulsive therapies discussed is likely to be more beneficial for treatment of the patients medical condition than inpatient admission for lidocaine infusions. Based upon the information set forth above, the requested services are 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 2

A 20-year-old male enrollee has requested authorization and coverage for inpatient admission for lidocaine infusions for seven days. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees orthostatic headache. The physician reviewer found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. This patient is diagnosed with chronic migraine and new daily persistent headache. He has already had treatment with a couple of therapeutic preventative interventions without benefit. There are multiple treatments that have not yet been explored, and are generally considered first-line for the preventative therapy of chronic migraine.  These include Topamax, which is the only oral medicine that has adequate evidence as a preventive for chronic migraine, as well as Botox, which is the only U.S. Food and Drug Administration (FDA) indicated treatment for chronic migraine. Botox has adequate success rates with minimal side effects. Intravenous lidocaine has some evidence for headache conditions (Matharu, et al). However, the data regarding its use for chronic migraine is mixed and weak. There are no specific treatments indicated for new daily persistent headache, which is typically treated based on the phenomenology of the primary headache disorder that otherwise resembles, such as migraine. As standard treatments have not yet been pursued, and there are several standard treatments that have proven effectiveness, inpatient treatment with intravenous lidocaine is 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 requested services are 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 20-year-old male enrollee has requested authorization and coverage for inpatient admission for lidocaine infusions for seven days. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees orthostatic headache. The physician reviewer found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of support in the medical literature for the requested services in this clinical setting. In this case, the patient was diagnosed with chronic headache of migraine type with positional component. There is a lack of controlled studies supporting the safety and efficacy for lidocaine infusions for treatment of the patients medical condition. Based upon the information set forth above, the requested services are 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 Overturned

Summary Reviewer 1

A 42-year-old female enrollee has requested reimbursement for supraorbital, occipital and suprascapular nerve blocks of the occipital nerve performed on 10/3/16 and 10/20/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees chronic headache. 
 The physician reviewer found that Neuralgia is a type of neuropathic pain that can be chronic of paroxysmal, shock, lightening like, burning, dull or ache type pain that follows a peripheral or cranial nerve area and can also spread to other areas. Inherent in the definition there cannot be a neurologic deficit correlating with the nerve affected. Attacks can either be spontaneous or provoked by direct stimulation or palpation of other trigger point zones. Occipital neuralgia can specifically refer to pain and or headache in the occipital region in the greater, lesser, or third occipital nerve areas which can also be accompanied by dysesthesia or decreased sensation in the nerve distribution. On examination, patients would have tenderness with palpation over the occipital area. Another key element to the diagnosis is response to occipital nerve blocks, which this patient also exhibited. The treatment of choice for occipital neuralgia is a local occipital nerve block due to its ability to relieve pain as well as act as a diagnostic marker. Considering the information provided by the provider, this patient has chronic migraine and occipital neuralgia. The treatment that she has received has reportedly provided therapeutic benefit. Moreover, this patient has tried several therapeutic options for her condition without any benefit and with some documented adverse effects. 
This patient meets the criteria for chronic migraine. She has a long history of chronic migraine and failure with several treatment modalities. Included in that history of failure, the majority if not all prophylactic and abortive therapeutic options were discontinued due to lack of effectiveness. There are various studies with evidence to suggest that peripheral nerve blocks of the supraorbital, supratrochlear, and occipital nerves are effective in the management of migraine. This patient has a well-documented and comprehensive history of unresponsiveness to other medical therapies. However, she has demonstrated response to the performed nerve blocks, which is consistent with available literature regarding nerve blocks. According to the current data and this patients medical history, the supraorbital, occipital, and suprascapular nerve blocks of the occipital nerve on 10/3/16 and 10/20/16 were likely to have been more beneficial for treatment of this patients medical condition than any available standard therapy.
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 Overturned

Summary Reviewer 2


A 42-year-old female enrollee has requested reimbursement for supraorbital, occipital and suprascapular nerve blocks of the occipital nerve performed on 10/3/16 and 10/20/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees chronic headache. 
 The physician reviewer found that there is sufficient support in the medical literature for the services at issue in this clinical setting. Occipital nerve blocks are an established treatment method for the management of chronic headache and chronic migraine. Peer reviewed medical literature has documented its efficacy over placebo controlled blinded studies. This patient has well documented chronic migraine and has failed numerous treatment modalities but was responsive to occipital nerve blocks. As such, the supraorbital, occipital, and suprascapular nerve blocks of the occipital nerve on 10/3/16 and 10/20/16 were likely to have been more effective than the other options for treating this patients medical condition. 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 Overturned

Summary Reviewer 3


A 42-year-old female enrollee has requested reimbursement for supraorbital, occipital and suprascapular nerve blocks of the occipital nerve performed on 10/3/16 and 10/20/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees chronic headache. 
 The physician reviewer found that the medical evidence do not support the use of occipital nerve blocks, supraorbital and suprascapular blocks for the treatment of migraine or other type headaches. The blocks are supported for diagnostic purposes but are not supported for therapeutic treatment. Peer reviewed medical literature have not shown long term benefit of occipital nerve blocks for treatment of migraine. In 2015, Dilli and colleagues noted that greater occipital nerve block does not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. In sum, the supraorbital, occipital, and suprascapular nerve blocks of the occipital nerve on 10/3/16 and 10/20/16 were not likely to have been more efficacious than the standard treatment options available for treating this patients medical condition. 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 57-year-old female enrollee has requested reimbursement for the hysterectomy performed on 1/16/17. The Health Insurer has denied this request indicating that the surgery at issue was not medically necessary for treatment of the enrollees post-menopausal bleeding. The physician reviewer found that the records provided for review document that this patient presented with a history of post-menopausal bleeding that interfered with her activities of daily living and did not responded to medical management. Per the American College of Obstetricians and Gynecologists (ACOG), late peri-menopausal patients may be treated with cyclic progestin therapy, low-dose oral contraceptive pills, the levonorgestrel intrauterine device (IUD), or cyclic hormone therapy. The ACOG further noted that women who have completed childbearing, in whom medical therapy has failed, or who have contraindications to medical therapy are candidates for hysterectomy without cervical preservation. Appropriate treatment includes an endometrial ablation or hysterectomy. Endometrial ablation is not definitive therapy and is generally considered for premenopausal women. This patient was treated with conservative management, which was hormonal therapy appropriate for her age. Given the ACOG recommendations for patients who have failed conservative therapy in this clinical setting, the hysterectomy performed on 1/16/17 was medically necessary for treatment of this patients post-menopausal bleeding. Based on the foregoing discussion, the surgery at issue was 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 42-year-old female enrollee has requested reimbursement for hip arthroscopy performed on 4/05/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees hip pain. The physician reviewer found that this patient underwent right hip arthroscopy on 4/05/18 for revision treatment of femoroacetabular impingement and synovial cyst. She was status post three prior right hip arthroscopic procedures for treatment of femoroacetabular impingement, labral tear, and synovial cyst, with persistent and worsening right hip pain. Functional limitations were documented in activities of daily living. Clinical examination findings were consistent with MRI evidence of a synovial mass, possible labral tearing, and mixed femoroacetabular impingement, and x-ray evidence of Tonnis grade 1 changes. She had tried and failed extensive conservative management, including activity modification, physical therapy, home exercise, injections, and NSAIDs. Surgery was recommended to include revision hip arthroscopy for lysis of adhesions, decompression of her femoroacetabular impingement, evaluation of her cartilage, and removal of lesion anterior to her hip joint. Operative findings confirmed mixed femoroacetabular impingement with subspine component, labral deficiency, loose bodies, synovial cyst, and chondromalacia of the anterior superior acetabulum and femoral head. Current evidence based medical guidelines support arthroscopic hip revision surgery for residual femoroacetabular impingement for functional outcome improvement, including Cam decompression, identification and treatment of subspine impingement, labral preservation/reconstruction, and capsular preservation/plication. Therefore, hip arthroscopy provided on 4/05/18 was medically necessary for the treatment of this patient. Therefore, 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 41-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 1/17/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that 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 assay is a study of 31 genes in an individualas melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma class, in patients who underwent a sentinel node biopsy, which this patient has not had. It is not at all clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not known if the DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, DecisionDx-Melanoma testing performed on 1/17/20 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 41-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 1/17/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that various (mostly retrospective) studies of prognostic gene expression profiling (GEP) suggest its role as an independent predictor of worse outcome, although not superior to Breslow thickness or sentinel lymph node biopsy status. It remains unclear whether this GEP profile is reliably
predictive of outcome across the risk spectrum of melanoma. Prospective validation studies are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Existing and emerging GEP platforms and other prognostic techniques should also be compared with optimized contemporary multivariable phenotypic models. Therefore, DecisionDx-Melanoma testing performed on 1/17/20 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 41-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 1/17/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of
invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is very novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Therefore, DecisionDx-Melanoma testing performed on 1/17/20 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 50-year-old male enrollee has requested authorization and coverage for transcatheter insertion of permanent leadless implantable pacemaker. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the accepted indications for leadless pacemakers generally include younger patients, those with difficult venous access or other anatomical issues, making transvenous placement or pocket creation problematic, certain sports or work-related use of the upper extremity where long-term lead trauma might be expected and absence of need for dual chamber pacing, such as permanent atrial fibrillation. This patient has none of these indications. Moreover, uncertainties exist about the long-term clinical outcomes associated with leadless pacemakers because most studies only report acceptable pacing capture thresholds as the primary efficacy endpoint. Therefore, transcatheter insertion of permanent leadless implantable pacemaker is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 50-year-old male enrollee has requested authorization and coverage for transcatheter insertion of permanent leadless implantable pacemaker. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient has a history of pacemaker placement and a recent episode of syncope caused by imminent battery failure in the existing pacemaker. He was advised to have replacement with a leadless pacemaker.  The requested leadless pacemaker is standard of care and it decreases the risk of infections. Therefore, transcatheter insertion of permanent leadless implantable pacemaker is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 50-year-old male enrollee has requested authorization and coverage for transcatheter insertion of permanent leadless implantable pacemaker. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the current medical evidence has not established the superior efficacy of the requested services. Leadless pacing systems have utilized a self-contained system that includes both the pulse generator and the electrode within a single unit that is placed into the right ventricle via a transvenous approach. One system is now U.S. Food and Drug Administration (FDA) approved and commercially available. However, placement of a leadless cardiac pacemaker may lead to right ventricle dysfunction and may contribute to worsening tricuspid regurgitation. Longer term follow-up is needed to assess the safety and efficacy of these devices. Therefore, transcatheter insertion of permanent leadless implantable pacemaker is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 48-year-old female has requested reimbursement for Anser IFX testing performed on 9/04/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns colitis. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  This is a complex case in which a patient who was initially diagnosed with ulcerative colitis underwent colectomy with J-pouch.  Ultimately, she was found to have complicated pouch disease presumably because the underlying disease was, in fact, Crohns disease.  The patient was placed on maximal doses of Remicade and had a marginal response clinically. Remicade is the drug of choice for treatment.  In this clinical setting, it was medically reasonable to check drug and antibody levels.  Therefore, Anser IFX testing performed on 9/04/15 was likely to have been superior over other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.