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

Summary Reviewer 

This patient is a 24-year-old female who was admitted for detoxification services on 5/23/20 after a heroin overdose. The patient has requested reimbursement for substance abuse residential treatment provided from 6/02/20 through 6/20/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for residential treatment services provided from 6/2/20 through 6/20/20. ASAM criteria focuses on six dimensions to determine the appropriate level of care. With regard to dimension I, acute intoxication of withdrawal potential, the patient was initially admitted to detoxification services and managed for withdrawal. She had Clinical Institute Withdrawal Assessment (CIWA) scores ranging from 7 to 15 after moving to the residential treatment center. Thus, her withdrawal needs could have been managed in Level 3.5 setting. In terms of dimension II, biomedical conditions, this patient did not have any identified medical problems. With regard to dimension III, emotional, behavioral, or cognitive conditions, the patient has been diagnosed with bipolar disorder. She was noted to have hallucinations and delusional thinking while in the residential treatment center that affected her insight into her condition. She also was noted to be impulsive and needed frequent boundary setting. Although this patientas mental status permitted participation in the residential treatment program, the records noted significant functional deficits that were sufficiently severe that she was not likely to maintain mental stability or abstinence if treatment was not provided in a non-residential setting. In terms of dimension IV, readiness to change, the patient was noted to be in the contemplative stage of change. She had experienced persistent psychotic symptoms and significant overdosage as serious consequences. She was noted to blame relationships and others for her ongoing usage. Thus, despite experiencing serious consequences, the patient had marked difficulty in understanding the relationship between substance use and her impaired coping skills and level of functioning, often blaming others for her addiction problems. With regard to dimension V, relapse, continued use, or continued problem potential, the patient did not recognize relapse triggers and lacked insight into benefits of continuing care. In terms of dimension VI, recovery environment, the patientas social network included regular users of drugs such that recovery goals are assessed as unachievable at a less intensive level of care. In sum, the submitted records support the medical necessity of the services at issue. Therefore, substance abuse residential treatment provided from 6/02/20 through 6/20/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The parent of a 10-year-old male has requested authorization and coverage for Nutropin AQ Nuspin 20. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that short stature is a known feature of children with congenital adrenal hyperplasia. The short stature is due to advanced bone age due to androgens from under treatment and can also be due to overtreatment from glucocorticoids. Therefore, a right balance of glucocorticoids is recommended to achieve optimal adult height. This patient had advanced bone age that has been stable after initiation of treatment with Cortef. His estimated adult height is 174 cm, based on a height of 152.2 cm on 2/08/19 and advanced bone age of 13 years six months. This is a normal adult height prediction and does not justify treatment with growth hormone therapy. This patient has good linear growth as indicated on his growth chart. Neither the patients current height nor the estimated adult height is 2.25 standard deviations below the mean, and this patient does not have idiopathic short stature. The current medical evidence does not support the requested medication in this clinical setting. Therefore, Nutropin AQ Nuspin 20 is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 60-year-old male enrollee has requested reimbursement for Oncotype DX prostate cancer assay (CPT code 84999) testing provided on 4/11/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees elevated prostate-specific antigen (PSA). The physician reviewer found that Oncotype DX prostate cancer testing provides valuable information to help the patient and provider to make a decision whether to provide watchful waiting or proceed with surgery or radiation therapy. The Oncotype DX is clinically indicated to guide management of the patients prostate cancer and is the standard of care in this patient population. All told, the Oncotype DX prostate cancer assay (CPT 84999) testing performed on 4/11/16 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

A 60-year-old male enrollee has requested reimbursement for Oncotype DX prostate cancer assay (CPT code 84999) testing provided on 4/11/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees elevated prostate-specific antigen (PSA). The physician reviewer found that once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features such as the grade of tumor and PSA level. This helps guide the most appropriate therapy for patients taking into account their age and co-morbidities. The Oncotype DX prostate cancer assay is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score (GPS). A validation study was presented at the American Urological Association meeting in 2013 involving 395 patients (Cooperberg, et al; Eastman). The GPS identified patients that had very low risk disease that could be followed rather than referred for surgery. The Oncotype DX is a medically appropriate to better stratify patients with localized disease. All told, the Oncotype DX prostate cancer assay (CPT 84999) testing performed on 4/11/16 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

A 60-year-old male enrollee has requested reimbursement for Oncotype DX prostate cancer assay (CPT code 84999) testing provided on 4/11/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees elevated prostate-specific antigen (PSA). The physician reviewer found that the Oncotype DX prostate cancer assay (CPT 84999) testing performed on 4/11/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. This patient underwent genomic testing to help in clinical decision making. In this case, given the patients Gleason score of 6, PSA, and volume of cancer detected, current guidelines without genomic testing place this patient at low risk. In conclusion genomic testing 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 58-year-old female enrollee has requested authorization and coverage for Synvisc One injection. 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 an exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Per the literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, there is a history of lasting benefit from viscosupplementation over the last several years. Furthermore, the patients options are limited. She has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Therefore, the requested Synvisc One injection is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 52-year-old male enrollee has requested reimbursement for gene testing (gene expression profiling) performed on 10/31/18. 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. The National Comprehensive Cancer Network guidelines state that 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. This patients pathology indicates low risk disease. Therefore, gene testing (gene expression profiling) performed on 10/31/18 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 male enrollee has requested reimbursement for gene testing (gene expression profiling) performed on 10/31/18. 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, with some minor updates. 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 upon the risk of metastasis. Gerami reported on 217 cases, with good correlation between DecisionDx-Melanoma testing class and risk of recurrence in patients undergoing sentinel node biopsy. It is not clear how the five-year DecisionDx-Melanoma testing data compares to the ten-year Balch data. Most importantly, it is not clear that the DecisionDx-Melanoma testing assay can be used to make clinical decisions. In sum, gene testing (gene expression profiling) performed on 10/31/18 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 male enrollee has requested reimbursement for gene testing (gene expression profiling) performed on 10/31/18. 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 to 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 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 (gene expression profiling) performed on 10/31/18 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 

A 62-year-old male enrollee has requested reimbursement for a PET scan performed on 11/06/19. 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 the standard differential diagnosis of an anterior mediastinal mass, whether discovered incidentally or following symptoms, is lymphoma versus metastases from a previously undiagnosed malignancy versus germ cell tumor versus thymoma. The use of PET/CT scan is valuable for multiple reasons. First, it can establish whether a lesion is highly aggressive. A lesion that has a high avidity for fluorodeoxyglucose (FDG) is more likely to be malignant, whereas a lesion that does not take up FDG could conceivably be followed without intervention. Second, the PET/CT scan will better establish whether the lesion is confined to the chest, or whether there might be distant disease. Finally, a PET/CT scan will possibly direct the provider performing the biopsy to a lesion that is more accessible than the mediastinum. The National Comprehensive Cancer Network also sees the clinical utility of PET/CT scanning in the initial work-up of suspected Hodgkin disease. In this patients case, the PET/CT scan was valuable in the management of this patient. The medical evidence supports the services at issue in this clinical setting. Therefore, the PET scan performed on 11/06/19 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 41-year-old male enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) provided from 10/02/20 through 11/20/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that in his case, the records document treatment-resistant, recurrent major depressive disorder. Per the submitted documentation, TMS was an effective treatment for patient in 2019, despite needing maintenance treatments at that time. During this episode of depression, the patient again presents with similar Patient Health Questionnaire 9 (PHQ-9) scores as in early 2019 pre-treatment. The medical evidence supports TMS in this clinical setting. Therefore, TMS provided from 10/02/20 through 11/20/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 41-year-old male enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) provided from 10/02/20 through 11/20/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that this patient has failed multiple medication trials and continues to have depressive symptoms. He had experienced a positive response to TMS in the past, with an over 50% reduction in symptoms during that time. TMS is currently approved for treating patients who are suffering from the acute phase of major depressive disorder. Given that this patient was still experiencing an acute episode, the medical evidence supports continued treatment. Therefore, TMS provided from 10/02/20 through 11/20/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 41-year-old male enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) provided from 10/02/20 through 11/20/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that depression is a common mental disorder and a leading cause of morbidity. Approximately 30% of patients do not respond to standard medication and/or psychotherapy. The evidence on repetitive TMS (rTMS) for depression is adequate, although the clinical response can be variable. The majority of patients who achieve remission following rTMS continue to stay in remission at the end of one year. Perera and colleagues noted, aTMS therapy is recommended for use as a subsequent option in patients who previously benefited from an acute treatment course and are experiencing a recurrence of their illness (continuation or maintenance).a This consensus statement also recommended that aTMS can be reintroduced in patients who are relapsing into depression after initially responding to TMS treatment.a Given that the patientas depressive symptoms improved by over 50% during this course of TMS, the records document that the requested treatment is superior to the standard of care, which the patient has previously tried and not responded to. Therefore, TMS provided from 10/02/20 through 11/20/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 49-year-old transgender female enrollee has requested reimbursement for breast augmentation provided on 3/26/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. This patient had well-documented gender dysphoria related to masculine features of her body. The records documented social anxiety and depression. Feminizing mammoplasty under these circumstances is medically necessary for the treatment of gender dysphoria. World Professional Association for Transgender Health (WPATH) criteria for surgery state that surgical procedures for patients with gender dysphoria may include augmentation mammoplasty, genital surgery and other interventions, such as facial feminization surgery, lipofilling and thyroid cartilage reduction. The current medical evidence supports the services at issue in this clinical setting. Therefore, breast augmentation provided on 3/26/18 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 50-year-old female enrollee has requested authorization and coverage for Aimovig. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient has a history of migraines. She has already been on several nonspecific oral preventives for migraines. The medical evidence support the use of Aimovig for the preventive management of migraines in adults. Per American Headache Society guidelines, prevention is warranted for people with three migraine days monthly. In this patients case, she reported that she experiences five to six migraines per month. Guidelines also noted that individuals who fail greater than two prior preventives are appropriate for calcitonin gene-related peptide (CGRP) therapies. She meets this guidance. In addition, the Health Insurer noted that the patient was started on Aimovig 140 mg. Review of the data regarding Aimovig reveals that this is a more effective dose than 70 mg. It is appropriate to start patients on what is likely to be most effective as a standard part of clinical care. Therefore, Aimovig (erenumab-aooe subcutaneous solution auto-injector 140 mg/mL) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 53-year-old male enrollee has requested reimbursement for emergency department visit (99285) provided on 2/18/19. 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 CPT code 99284 describes an emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patients and/or familys needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function. This level of billing would be an appropriate level of service in this patients case. All told, 99285 was not medically necessary for the treatment of this patient.