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

Summary Reviewer 1

The patient is a 46-year-old female with severe cervical spondylosis with progressive involvement of C5-6 and C6-7 levels and associated radiculopathy. The patient has requested reimbursement for cervical artificial discectomy performed on 4/13/17. The Health Insurer has denied this request indicating that the surgery at issue was considered investigational. Cervical disc arthroplasty has been approved by the US Food and Drug Administration (FDA) and has been demonstrated preserve some motion and provide decreased incidence of adjacent level disease when compared with anterior cervical discectomy and fusion. The need for revision surgery is also less than anterior cervical discectomy and fusion (Gao, et al; Wu, et al; Radcliff, et al). For these reasons, the cervical artificial discectomy performed on 4/13/17 was 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 surgery at issue was 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

The patient is a 46-year-old female with a three-year history of chronic neck pain radiating to the bilateral upper extremity with numbness in both hands and feet. A 3/30/17 cervical spine magnetic resonance imaging (MRI) impression documented straightening of the normal cervical lordotic curve. At C5-6, there was subacute reactive marrow beneath the left endplates, 1-2 mm retrolisthesis, 2 mm broad-based disc bulge with no impingement, lateral disc osteophytic spurring, greater on the left, and mild to moderate left neuroforaminal narrowing. At C6-7, there was a 1-2 mm central disc protrusion, and minimal right uncovertebral hypertrophic changes but no significant stenosis. The 3/22/17 provider noted that the patient was seen for follow-up. She underwent facet blocks from C5-7 three times and did well each time, but her symptoms recurred. X-rays showed greater collapse in the C5-6 level than when she was first evaluated, as well as C6-7 intervertebral collapse. She was not responding to conservative management any longer. A 3/22/17 cervical spine x-ray report documented loss of disc height at C5-6, and mild motion on flexion/extension views from C2-3 through C4-5. A 4/13/17 operative report indicated that anterior cervical discectomies were performed at C5-6 and C6-7 with insertion of the intervertebral disc replacement prosthesis C5-6 and C7. The patient has requested reimbursement for cervical artificial discectomy performed on 4/13/17. The Health Insurer has denied this request indicating that the surgery at issue was considered investigational. In the peer-reviewed medical literature, Davis and colleagues performed a prospective, randomized, controlled multicenter clinical trial on two-level symptomatic degenerative disc disease. The authors found that use of cervical arthroplasty at two contiguous levels provided advantages over two-level anterior cervical discectomy and fusion. Coric and colleagues reported that the use of anterior cervical surgery for contiguous two-level pathology as safe and effective. The authors concluded that total disc replacement was superior to anterior cervical discectomy and fusion for the treatment of two-level contiguous pathology at five years. Moreover, the US Food and Drug Administration (FDA) has approved the use of the Mobi-C and Prestige discs for well selected patients who have failed conservative treatment. This patient met the FDA and evidence based medical criteria for the two level artificial disc replacement performed on 4/13/17. Therefore, the cervical artificial discectomy performed on 4/13/17 was 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 surgery at issue was 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

The patient is a 46-year-old female with a history of neck pain and numbness in both hands and feet, greater on the left. On 3/22/17, the patient presented for follow up status post facet blocks from C5-7 with temporary relief and recurrence of symptoms. By report, x-rays showed increased collapse of C5-6 level and C6-7 intervertebral collapse. Magnetic resonance imaging (MRI) demonstrated significant foraminal stenosis at both levels. The patient has failed conservative management and the provider recommended two level cervical disc replacement. The patient has requested reimbursement for cervical artificial discectomy performed on 4/13/17. The Health Insurer has denied this request indicating that the surgery at issue was considered investigational. The medical records show that the patient has evidence of three levels of cervical degeneration from the C3 to C7 levels. However, there is a lack of well conducted randomized controlled clinical trials demonstrating superior health outcomes with use of cervical artificial discectomy compared to standard available interventions. All told, the cervical artificial discectomy performed on 4/13/17 was 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 surgery at issue was 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 

The patient is a 60-year-old female with a history of progressively worsening left-sided low back pain radiating to the left buttock and down the left anterolateral thigh associated with paresthesias in the thigh. The patient has requested coverage for left side injections. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that lumbar epidural steroid injections under fluoroscopic guidance are commonly used for treatment of low back and lower extremity radicular pain. As noted in the articles referenced here, these procedures are safe and effective. The commonly used approaches for the epidural steroid injections include the interlaminar and transforaminal. These lumbar epidural injections have been used extensively to treat radicular pain and paresthesias, as in this case. Among interlaminar and transforaminal, the transforaminal epidural injections are more widely used for treatment of lumbar and lower extremity pain. The potential advantages of transforaminal over interlaminar include more targeted delivery of the injectate steroid to the site of the nerve root compressive pathology, thereby reducing the swelling, inflammation, and nerve root compression with associated pain relief. Facet joint injections are also useful in cases of facetogenic pain, although not for radicular pain. If the provider feels the necessity to use both, in light of the degenerative changes noted on x-rays, facet injections should also be useful. Therefore, the requested left side injections are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 51-year-old male enrollee has requested reimbursement for photodynamic therapy (CPT 96567) and aminolevulinic acid HCL for topical administration, 20% single unit dose (J7308) performed on 6/20/17 and 6/28/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee who has a history of skin cancer. The physician reviewer found that the documentation provided supports a portion of the services at issue in this clinical setting. This patient has a history of multiple non-melanoma skin cancers and actinic keratosis but has failed treatment with 5-fluorouracil. The use of photodynamic therapy with aminolevulinic acid of non-hypertrophic actinic keratoses involving the scalp and face have been shown to be an effective therapy. This patient had treatment of the face on the first session and his left arm and left hand were treated during the second session.  As there is support in the medical literature for the use of photodynamic therapy with aminolevulinic acid for the treatment on actinic keratosis of the face and scalp, a portion of the services at issue was medically necessary for treatment of this patient.  Photodynamic therapy (CPT 96567) and aminolevulinic acid HCL for topical administration, 20% single unit dosage form (J7308) of the face were medically necessary. However, photodynamic therapy (CPT 96567) and aminolevulinic acid HCL for topical administration, 20% single unit dosage form (J7308) of the left arm and left hand were not medically necessary for treating this patients medical condition. As such, a portion of the services at issue was medically necessary. Therefore, for the reasons stated above, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 58-year-old female enrollee has requested reimbursement for Afirma Thyroid Fine Needle Aspiration Analysis gene testing performed on 11/18/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign.  The Afirma test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  All told, Afirma Thyroid Fine Needle Aspiration Analysis gene testing performed on 11/18/14 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.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 58-year-old female enrollee has requested reimbursement for Afirma Thyroid Fine Needle Aspiration Analysis gene testing performed on 11/18/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue in this patients case.  In this case, the cytopathology report was consistent with suspicion of follicular neoplasm. This finding carries a risk of malignancy of 35%.  The genetic marker was consistent with suspicion for malignancy, which raises the risk of malignancy to 40%.  Submitting the specimen to Afirma testing was useful to confirm the recommendation for surgery.  However, it did not change the risk to change the recommendation.  In sum, Afirma testing did not provide additional benefit to the patient which would have altered patient management.  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 Overturned

Summary Reviewer 3


A 58-year-old female enrollee has requested reimbursement for Afirma Thyroid Fine Needle Aspiration Analysis gene testing performed on 11/18/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that there is sufficient support for the services at issue in this patients case.  The initial biopsy report was suspicious for follicular neoplasm.  The genetic testing noted that the right nodule was suspicious.  This was a major determining factor in delineating the further course of action to see if a possible surgical procedure was warranted.  Afirma testing is considered standard protocol in this clinical setting.  There is sufficient literature to indicate that this test can be performed to avoid unnecessary surgeries.  Thus, Afirma Thyroid Fine Needle Aspiration Analysis gene testing was likely to have been of greater benefit than other method 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.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 41-year-old male enrollee has requested authorization and coverage for myoelectric, upper extremity orthosis. The Health Insurer has denied this request indicating that the requested equipment is considered investigational for treatment of the enrollee who had sustained an injury to his upper right arm. The physician reviewer found that the patient is a 41-year-old male who sustained a right brachial plexus injury in December 2014. He underwent nerve and tendon grafting in July 2015 and February 2016 with less than expected recovery. He has a three out of five strength to his right hand and two out of five strength in his right shoulder and elbow. A Wilmer carrying orthosis has been utilized for static splinting but affords no functional benefit. Prior to the accident this patient was independent with all activities but he currently requires assistance with activities of daily living (ADL). The patient requested authorization and coverage for myoelectric, upper extremity orthosis. The Health Insurer denied the requested equipment as investigational for treatment of the patients medical condition.
The medical literature supports the superior efficacy of the requested equipment, in this clinical setting. The custom myoelectric elbow wrist orthosis will allow greater benefit than the standard static orthosis that this patient is currently utilizing. There are multiple studies proving the benefit of myoelectric orthoses for a plegic upper extremity. In a study by Ogce and Ozyalcin, they document the benefits of a myoelectrically controlled shoulder-elbow orthosis for brachial plexus injury. In this patients case, he has exhausted several conservative options including splinting, orthoses, therapy, and surgical nerve and tendon transfer. The myoelectric orthosis has been shown to improve function in a plegic extremity. The equipment would allow elbow flexion and extension with an articulated wrist.  Moreover, this equipment would facilitate independence with ADL, in this case. Currently, the patient requires assistance with his ADL. As such, the requested myoelectric, upper extremity orthosis, is likely to be more effective than the standard options available for treatment of this patient. Based upon the information set forth above, the requested equipment is 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 41-year-old male enrollee has requested authorization and coverage for myoelectric, upper extremity orthosis. The Health Insurer has denied this request indicating that the requested equipment is considered investigational for treatment of the enrollee who had sustained an injury to his upper right arm. The physician reviewer found that the patient is a 41-year-old male who sustained a right brachial plexus injury due to a motorcycle accident in 2014. He underwent occupational therapy, which included electrical stimulation and static splinting. In July 2015 and February 2016, he underwent surgical intervention to include nerve and tendon transfers. He has regained antigravity strength in the right hand.  His right shoulder and elbow have poor minus strength.  The documents noted that the patient would like full independence and would like to return to work. The patient was an airline pilot. Myoelectric elbow wrist orthosis was prescribed to improve function requiring bimanual activities. The patient requested authorization and coverage for myoelectric, upper extremity orthosis. The Health Insurer denied the request noting that the requested equipment is experimental/investigational for treatment of this patient. The medical literature regarding the requested equipment is limited to preclinical work, developmental work and small anecdotal reports reporting its potential for benefit. The equipment is not yet proven to provide functional improvements over what can be achieved through standard occupational therapy interventions with static orthoses and durable medical equipment used for assisting with self-care and other activities.  Further studies are required to determine its efficacy as compared to standard means of treatment. In this patients case, there are no indications that the patient requires the equipment to perform his activities of daily living.  Current commercially available iterations of this type of equipment remain heavy, bulky, difficult to don, and difficult to use on a practical basis.  As such, the equipments safety and efficacy, in this clinical setting, have not been established. Therefore, the requested myoelectric, upper extremity orthosis is not likely to be more effective than standard equipment available for treatment of this patients medical condition.  Based upon the information set forth above, the requested equipment is 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 3


A 41-year-old male enrollee has requested authorization and coverage for myoelectric, upper extremity orthosis. The Health Insurer has denied this request indicating that the requested equipment is considered investigational for treatment of the enrollee who had sustained an injury to his upper right arm. The physician reviewer found that the patient is a 41-year-old male who has sustained a permanent right brachial plexus injury (BPI) resulting in functional paralysis of his dominant right arm. The patient was involved in a motorcycle accident injuring his upper right arm. The records also indicate that the patient has undergone conservative therapies to improve function of this limb. The patient requests authorization and coverage for myoelectric, upper extremity orthosis. The Health Insurer has denied this request indicating that the equipment is investigational for treatment of this patient. There is sufficient support in the medical literature for the efficacy of the requested equipment in this clinical setting. The equipment is to assist in upper extremity function for an individual with weakness but not paralysis of the upper limb.  The current medical literature indicates that greater functional ability may occur, for motivated patients, from such a powered exoskeleton equipment when compared to traditional orthosis. The medical records outline extensive rehabilitation attempts in a tertiary care setting leading to the current request for a myoelectric exoskeleton to improve the patients upper extremity function. This patient has tried various standard options like splinting, surgery and static orthoses in attempt to restore function to his right arm. As such, the medical record, in this case, presents compelling evidence for the requested myoelectric orthotic device for treatment of this patients functional paralysis of his upper right limb. In sum, the myoelectric, upper extremity orthosis is likely to be more efficacious than other modalities available for treatment of this patient. Based upon the information set forth above, the requested equipment is 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 Upheld

Summary Reviewer 1


A 59-year-old male enrollee has requested reimbursement for advanced lipoprotein testing provided on 3/11/16. The Health Plan has denied this request indicating that the service at issue was considered investigational for the enrollees hypertension. The physician reviewer found the advanced lipoprotein testing provided on 3/11/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Advanced lipoprotein analysis has not been approved in the current guidelines from the American College of Cardiology (ACC). The ACC guidelines recommend use of standard risk factors and standard lipid panels in managing cardiovascular risk. The ACC has also moved away from treating to target lipid values and favor a simpler approach to provide standard doses of moderate strength statins to patients at increased risk, based on outcome studies. This recommendation is based on consensus by experts who have reviewed the current literature. Therefore, the testing at issue 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.