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

Summary Reviewer 2

A 58-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 2/20/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue. The treatment of this patient would not change based on the results of this testing. There is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care. There is a paucity of published data to support its routine use currently. At this time, there is a need for clinical trials to determine the utility of the results of the test to effect health outcomes. In sum, DecisionDx-Melanoma testing performed on 2/20/18 was not likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 58-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 2/20/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma testing should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the treatment of this patients melanoma. This testing is not expected to impact the treatment or outcome of this patients melanoma. Thus, DecisionDx-Melanoma testing performed on 2/20/18 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were 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 Upheld

Summary Reviewer 

A 44-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 8/26/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found that Tomosynthesis provides advantages relate to the tomographic nature of tomosynthesis and the associated ability to separate dense glandular elements from underlying architectural distortion. However, the technique is new and there is a lack of long-term studies showing an increased survival rate when tomosynthesis has been used versus cases where two-dimensional (2D) imaging alone has been performed. According to Friedewald and colleagues Addition of tomosynthesis to digital mammography was associated with a decrease in recall rate and an increase in cancer detection rate. Further studies are needed to assess the relationship to clinical outcomes. In sum, the use of 2D imaging alone is supported by the peer-reviewed literature, however the addition of tomosynthesis was not medically necessary. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 57-year-old male enrollee has requested reimbursement for orbitotomy without bone flap (right and left) and conjunctivoplasty reconstruction performed on 8/26/14.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found based on the history of failed conservative management for the patients infection, the surgical exploration and scar release were medically necessary.  The patient had an unusual presentation of canalicular and orbital infection and did not improve with antibiotic treatment and canalicular debridement.  There is no evidence in the medical literature to suggest additional intravenous antibiotic or other alternative management would be preferable to surgical care for this case where oral antibiotics had already failed.  All told, orbitotomy without bone flap (right and left) and conjunctivoplasty reconstruction performed on 8/26/14 were medically indicated 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 62-year-old male enrollee has requested reimbursement for laboratory services provided on 9/06/18. 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 prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also 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 and colleagues reported on its use in 156 cases, but there was insufficient follow-up to determine the actual value of the assay. It is not clear how the ten-year Balch data compares to the five-year DecisionDx-Melanoma data. Furthermore, it is not clear if the assay can be used to make clinical decisions. Therefore, laboratory services provided on 9/06/18 were 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 62-year-old male enrollee has requested reimbursement for laboratory services provided on 9/06/18. 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 had an early stage melanoma with good prognostic features. The National Comprehensive Cancer Network guidelines state 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. 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. In sum, laboratory services provided on 9/06/18 were 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 62-year-old male enrollee has requested reimbursement for laboratory services provided on 9/06/18. 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 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 the DecisionDx-Melanoma test has not made it part of routine analysis after sentinel lymph node biopsy. There has 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, laboratory services provided on 9/06/18 were 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 seven-year-old male. He has been diagnosed with mixed receptive/expressive speech disorder, phonological disorder and severe apraxia of speech. The patientas parent has requested reimbursement for speech therapy provided from 1/01/19 through 12/30/20. 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 the submitted documentation supports the services at issue in this clinical setting. The patient has mixed receptive/expressive speech disorder, phonological disorder and severe apraxia of speech. His speech and language impairment is severely impeding his ability to communicate with his family, peers and teachers. He has been documented as consistently attending therapy sessions, and to be making progress towards goals, with new goals subsequently being introduced by the therapist. Law and colleagues performed a review on speech and language therapy interventions for children with primary speech and language delay or disorder. The authors noted, aOverall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. The evidence for expressive syntax difficulties is more mixed, and there is a need for further research to investigate intervention for receptive language difficulties.a Liu and colleagues noted, aThe ability to communicate effectively with others is central to childrenas development. Delays or disruptions due to isolated expressive language delay, articulation errors, multiple sound production errors with motor planning deficits, or mixed expressive and receptive language delay, often bring widespread consequences.a Capone Singleton noted that late talking in children who do not receive professional intervention places them at risk for lifelong disability. OaHare and Bremner emphasize the need for comprehensive speech and language assessment, and speech therapy, for children with speech and language difficulty. Therefore, speech therapy provided from 1/01/19 through 12/30/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 64-year-old male who has been diagnosed with melanoma. The patient has requested reimbursement for unlisted multianalyte assay with algorithmic analysis performed on 12/18/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that the National Comprehensive Cancer Network guidelines state, aCommercially 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.a This patient has an early stage melanoma without adverse pathologic features. There is a lack of support for the services at issue in this clinical setting. Therefore, unlisted multianalyte assay with algorithmic analysis performed on 12/18/19 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a nine-year-old female with no significant past medical history with early puberty and short stature. The patientas parent has requested authorization and coverage for Norditropin Flexpro 10 mg/1.5. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that in clinical practice, growth hormone therapy is considered if the predicted adult height is below the normal range. This corresponds to an adult height less than 63 inches (160 cm) for males and less than 59 inches (150 cm) for females. This is also one of the recommendations given by the U.S. Food and Drug Administration (FDA) when deciding to treat idiopathic short stature. Grimberg and colleagues recommended growth hormone therapy to normalize adult height and avoid extreme shortness in children and adolescents with growth hormone deficiency for potential benefits associated with quality of life, physical health and psychosocial wellbeing. In this case, the patient has growth hormone deficiency diagnosed after growth hormone stimulation testing. She is growing with a borderline low growth velocity of around 5 cm per year. The patientas predicted adult height is more than two standard deviations below the mid-parental height of 65.25 inches. As the predicted adult height is below the normal standard deviation range for a female in the United States, growth hormone therapy is indicated. Therefore, Norditropin Flexpro 10 mg/1.5 is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


The parent of a three-year-old male enrollee has requested reimbursement for the FirstStepDx Plus testing performed on 12/14/15. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees autism spectrum disorder. The physician reviewer found that chromosome microarray is the standard of care for the evaluation of children diagnosed with ASD. The American College of Medical Genetics recommends CMA as an appropriate first-tier test for the evaluation of imbalances associated with intellectual disability, autism, and multiple congenital anomalies. The diagnosis of ASD should be done based on physical exam with a child and evaluation of behaviors. However, finding a genetic cause for the ASD requires further medical evaluation including the CMA. CMA can also provide information on other diagnoses including Angelman syndrome, Williams syndrome or 22q that may overlap with a diagnosis of ASD. Accordingly, the FirstStepDx Plus performed on 12/14/15 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 three-year-old male enrollee has requested reimbursement for the FirstStepDx Plus testing performed on 12/14/15. The Health Plan has denied this request indicating that the testing at issue is 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. CMA has become the standard of care to evaluate children with developmental delay, intellectual disability, autism spectrum disorders or multiple congenital anomalies. The medical literature supports the testing at issue as an important and mainstream tool in the practice of clinical genetics. Given the support in the peer-reviewed literature, FirstStepDx Plus performed on 12/14/15 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.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


The parent of a three-year-old male enrollee has requested reimbursement for the FirstStepDx Plus testing performed on 12/14/15. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees autism spectrum disorder.The physician reviewer found that chromosome microarray testing has been accepted as an appropriate first-line genetic testing since 2010 for the evaluation of autism (Manning and Hudgins). According to the American College of Medical Genetics and Genomics (ACMG) policy statement regarding the clinical utility of genetic and genomic testing, There is great clinical value in arriving at a precise medical diagnosis, enabling, among other things, identification of a disorders cause and prognosis, as well as frequently informing preventive and treatment modalities. Therefore, given that chromosome microarray is considered first-line testing for autism, and that management is often changed and/or affected by positive chromosome microarray results, FirstStepDx Plus performed on 12/14/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a 16-year-old female enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services provided from 2/16/16 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 the residential treatment center services provided from 2/16/16 forward were not and are not medically necessary for treatment of the patients medical condition. As of 2/16/16, the patient did not have any suicidal ideation. She did not have any mania, psychosis, or delusions. She was interactive with peers. She was engaged in her treatment and opening up more in group. Utilizing the Child and Adolescent Level of Care Utilization System (CALOCUS), the patients total score is a 15. This score correlates with a recommendation for outpatient treatment. The patient scored a two (2) on the risk of harm dimension as the patient had intermittent suicidal ideation without any prior history of suicide attempts. The patient had occasional impulsivity and had brief lapses in the ability to care for herself. The patient scored a two (2) in the functional status dimension as the patient had times where she would fast and/or restrict calories. However, there was no evidence that the patient was medically compromised or had any hypotensive episodes due to her lack of eating. The patient had no legal trouble, she attended school, and was cooperative with staff. The patient would demonstrate a significant improvement in functioning following a period of deterioration. The patient scored a two (2) in the co-morbidity dimension. The patient would have episodes of elevated anxiety which are moderately debilitating and would adversely affect the patient. The patient scored a three (3) in the environmental stress dimension. The patient moved to California and had a hard time adjusting. She was a victim of bullying and had frequent adverse interactions with her parents. The patient scored a one (1) in the environmental support dimension. Both parents were engaged and invested in the patients recovery and treatment. The patient scores a three (3) in the resiliency dimension. The patient has demonstrated inconsistent or equivocal capacity to deal with stressors, and recovery has been maintained for moderate periods of time, but only with strong professional support. The patient scored a two (2) in the engagement dimension. The patient is able to develop a positive relationship with providers. She passively cooperates in treatment planning and treatment. Given the patients total CALOCUS score of 15, as of 2/16/16, the patient can safely and effectively be treated at a lower level of care. For the reasons provided, 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 27-year-old transgender female enrollee has requested reimbursement for breast augmentation surgery performed on 6/13/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the current medical evidence supports the services at issue in this clinical setting. The records document gender dysphoria. The patient has been prescribed hormone therapy since February 2018, and she continued to experience severe dysphoria related to her chest. The World Professional Association for Transgender Health (WPATH) supports augmentation mammoplasty for the treatment of gender dysphoria. The WPATH position statement noted that breast augmentation...is often of greater practical significance in the patients daily life than genital surgery. The current medical evidence supports the services at issue in this clinical setting. Therefore, breast augmentation performed on 6/13/19 was medically necessary for the treatment of this patient.