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

Summary Reviewer 


A 22-year-old male enrollee has requested reimbursement for substance use partial hospitalization program (PHP) services provided from 9/19/16 through 10/13/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that based on the Level of Care Utilization System (LOCUS) criteria, as of 9/19/16, the patient met criteria for treatment in a less restrictive environment. The patients risk of harm score is two (2), low risk of harm. There was no documentation indicating that the patient had any suicide attempts. On 9/19/16 the patient had an appropriate mood, was participating in treatment, and did not have any suicidal ideation. The patients functional status score is three (3), moderate impairment. Due to the patients substance use, he has had a significant deterioration in his ability to fulfill responsibilities and obligations to a job or school. The patients medical, addictive and psychiatric co-morbidity score is three (3), significant co-morbidity. The patient had a co-morbidity of polysubstance use, depression, and anxiety. The patient did not have any serious medical problems and was medically stable. The patients recovery environment score is three (3), moderately stressful environment. The patient has significant discord with his family and his father recently passed away. The patients level of support score is three (3), limited support in environment. The patients treatment history score is three (3), equivocal response to treatment and recovery. The patient improves enough to be stepped down from RTC on 9/19/16. The patient has been sober since 8/31/16. The patients engagement and recovery status score is two (2), positive engagement and recovery. The documentation reports that the patient engaged and participated in treatment.  Based on these criteria, the patient has a total score of 19, which would meet criteria for an IOP. The patient continued to require treatment for his substance use, depression, and anxiety, but the patient could have continued treatment in a less restrictive environment. Therefore, substance use PHP services provided from 9/19/16 through 10/13/16 were not medically necessary for treatment of the patients medical condition. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 32-year-old female enrollee has requested reimbursement for the Prometheus Anser ADA testing performed on 4/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that monitoring patients on Humira with measurement of Humira levels and antibodies to Humira continues to be an area of intense investigation. Some data suggests that Humira levels correlate inversely with disease activity. However, there is a lack of controlled data which have identified the optimal drug level. Given the paucity of peer-reviewed medical literature supporting the clinical utility of the Anser ADA test in this circumstance, the Prometheus Anser ADA testing performed on 4/10/16 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 32-year-old female enrollee has requested reimbursement for the Prometheus Anser ADA testing performed on 4/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that in this case, Anser ADA was recommended to direct the management of this patients Crohns disease. The use of Anser ADA has not been clinically proven to improve patient outcomes. In addition, the effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with Humira may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear. The published studies on the use of antibodies and serum levels are retrospective or observational in nature (Karmiris, et al; Imaeda, et al; Lichtenstein, et al). The study by Karmiris and colleagues found no direct relationship between trough serum Humira (adalimumab) concentration or anti-adalimumab antibody and short-term treatment efficacy. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. Given this lack of support, the Prometheus Anser ADA testing performed on 4/10/16 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 32-year-old female enrollee has requested reimbursement for the Prometheus Anser ADA testing performed on 4/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that the Prometheus Anser ADA test is a quantitative measurement of serum adalimumab (ADA) and anti-ADA antibodies. Some evidence exists that low serum levels of adalimumab and/or the presence of antibodies to adalimumab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. However, in a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. Moreover, the reasons for therapeutic failures remain unclear. While there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al). Accordingly, the Prometheus Anser ADA testing performed on 4/10/16 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The patient is a 20-year-old male with a diagnosis of overactive bladder, insomnia, and anxiety. The patients associated symptoms include urinary frequency and nocturia.  Prior treatment has included overactive bladder anticholinergics and Myrbetriq. The patient has requested reimbursement for percutaneous tibial nerve stimulation (PTNS) provided on 10/16/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational. As noted in the medical literature, treatment in this clinical setting should including behavioral therapies with bladder training, bladder control strategies, pelvic floor muscle training, and fluid management as first-line therapy. Behavioral therapies may be combined with pharmacologic management. Overall, the guidelines suggest that PTNS is not recommended as a first- or second-line therapy and PTNS has not been proven to be superior to other alternatives. Thus, the PTNS provided on 10/16/17 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 service 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

The patient is a 20-year-old male with a history of urinary frequency, urgency, and nocturia. The patient has been treated with Ditropan, which was discontinued for constipation, and Myrbetriq, which provided minimal symptomatic improvement. The patient underwent the first of 12 scheduled percutaneous tibial nerve stimulation (PTNS) sessions on 10/16/17. The patient has requested reimbursement for PTNS provided on 10/16/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational. PTNS is considered third-line therapy in the current medical literature. The use of physical therapy or physical therapy combined with medication has been demonstrated to be more efficacious in the peer-reviewed medical literature. PTNS may be indicated in lieu of more invasive neuromodulation therapy to avoid implantable sacral nerve modulation in well selected patients. However, there is a lack of support for treatment with PTNS for this patient given the available standard therapies. All told, the PTNS provided on 10/16/17 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 service 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

The patient is a 20-year-old male with significant daytime frequency every hour and nocturia every four to six hours. The patient reportedly also has insomnia. The patient has tried pelvic floor muscle rehabilitation as well as multiple medications including oxybutynin, Vesicare, and Myrbetriq. The patient experienced side effects and no substantial improvement in his symptoms with these therapies. The patient is currently on desmopressin with some improvement. The patient has requested reimbursement for percutaneous tibial nerve stimulation (PTNS) provided on 10/16/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational. It was suggested that this patient undergo treatment with PTNS therapy for significant urinary frequency. The records document treatment failure with multimodal primary and secondary treatments for his condition. He does not wish to proceed with sacral neuromodulation or Botox injections. As noted in the medical literature, PTNS is performed as a salvage procedure. For these reasons, the PTNS provided on 10/16/17 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 service 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 42-year-old female enrollee has requested authorization and coverage for Intracept procedure. 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 the patient has a history of chronic low back pain. There is no radicular pain in the lower extremities. MRI scan showed scoliosis and Modic type 2 changes in the vertebral endplates at L4-5. The provider has requested the Intracept procedure. This procedure was approved by the U.S. Food and Drug Administration in 2016 as a minimally invasive radiofrequency ablation of the basivertebral nerve. Studies have shown that this led to significant improvement of pain and function at three-months in patients with chronic vertebrogenic related low back pain. The procedure is useful in individuals with chronic low back pain not responding to treatment for six months who have evidence of Modic changes. Current literature suggests that degenerated or damaged vertebral endplates can cause chronic low back pain without evidence of radiculopathy. Vertebrogenic chronic low back pain is not adequately diagnosed and treated by other minimally invasive procedures. The procedure is safe and effective for Modic changes causing vertebrogenic low back pain. Therefore, the requested Intracept procedure is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 52-year-old male with asthma. The patient has requested authorization and coverage for Nucala auto injector pen.  The physician reviewer found that Nucala is U.S. Food and Drug Administration (FDA) approved and supported by the medical evidence for the management of severe asthma in adults with an eosinophilic phenotype of asthma. Based on the available information, it is fair to characterize the phenotype of the patientas asthma as eosinophilic, based on an elevated peripheral eosinophil count of 180. It is important to note that peripheral eosinophils were elevated while the patient was taking systemic steroids, which is quite remarkable, as steroids typically drive down eosinophils. This information demonstrates that an eosinophilic process was at play. There is sufficient support for the requested medication in this clinical setting. Therefore, Nucala auto injector pen is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 61-year-old female enrollee has requested reimbursement for the monitored anesthesia care (MAC) services provide on 12/15/14 during a colonoscopy. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees colorectal screening.  The physician reviewer found that MAC is often utilized when it is important to have a dedicated anesthesiologist or anesthesia provider present during a particular diagnostic or therapeutic procedure. There are several indications for MAC including the patients clinical condition, comorbidities, past medical history, and the potential need to convert to a general anesthetic. MAC also includes the administration of other medications and agents necessary for patient safety and to support vital physiologic functioning. More than conscious sedation, MAC is characterized and defined by the anesthesiologists assessment and management of a patients actual or anticipated physiologic derangements or medical problems that may occur during a procedure. In this patients case, there was no documentation of a particular medical issue or comorbid disease process that would have required MAC services instead of conscious sedation. Typically it is appropriate to perform a screening colonoscopy with conscious sedation. During conscious sedation, a physician supervises or personally administers sedatives and/or analgesic medications during a diagnostic or therapeutic procedure. In this case, conscious sedation would have been appropriate. Thus, the MAC services provided on 12/15/14 were not medically necessary for evaluation of this patients medical condition. Given these above discussion, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 39-year-old male enrollee has requested authorization and coverage for autologous cultured chondrocyte and autologous chondrocyte implantation of the knee. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient presents with chronic severe localized right knee pain and swelling. Functional limitations are noted in activities of daily living. He underwent right knee arthroscopy with chondroplasty of the medial femoral condyle, lateral femoral condyle, and trochlear groove on 1/25/18. Operative findings confirmed multiple full thickness chondral defects of the medial femoral condyle, lateral femoral condyle, and trochlear groove, approximately 2.25 cm2, 4 cm2, and 1.25 cm2 respectively. There were minimal degenerative changes in the surrounding articular cartilage, and intact and stable knee with normal joint spacing. He has failed long-term extensive conservative treatment. U.S. Food and Drug Administration (FDA) indications support the use of matrix autologous chondrocyte implantation (MACI) for the treatment of single or multiple symptomatic, full thickness cartilage defects of the knee. Current evidence-based medical literature supports the use of MACI as safe and effective, with better long-term outcomes as compared to microfracture surgery. In this case, the requested MACI would be supported for the treatment of this patients medical condition as safe and effective given his young age and multiple defects. Therefore, the requested autologous cultured chondrocyte and autologous chondrocyte implantation of the knee are likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 39-year-old male enrollee has requested authorization and coverage for autologous cultured chondrocyte and autologous chondrocyte implantation of the knee. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that in this patients case, the records document a history of severe localized right knee pain. Upon failure of various conservative treatments, he underwent arthroscopic surgery of the right knee in January 2018 and was found to have multiple chondral defects of the medial and lateral femoral condyles and trochlear groove. The patient continues to experience localized severe pain and swelling in the knee. The provider has recommended autologous cultured chondrocyte implantation of the knee. Multiple chondral defects of the patellofemoral joint of the knee, as in this case, are common and can result in chronic pain and impair quality of life. The autologous chondrocyte implantation technique has evolved over the past 20 years and is associated with good to excellent mid-term and long-term results. The newest third-generation technique is matrix-induced autologous chondrocyte implantation. Physical examination and imaging is important to characterize the location and source of pain and identify associated injuries. In this case, arthroscopic evaluation has accurately localized the cartilage defects. Conservative measures have been exhausted. Therefore, surgical treatment is necessary to improve the quality of life. In sum, the requested autologous cultured chondrocyte and autologous chondrocyte implantation of the knee are likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 39-year-old male enrollee has requested authorization and coverage for autologous cultured chondrocyte and autologous chondrocyte implantation of the knee. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that in this case, the requested matrix autologous chondrocyte implantation (MACI) procedure is supported by the available literature for this patients condition. He has large unipolar chondral lesions of the weight-bearing portions of the distal femur with normal menisci. There are no noted arthritic changes on x-ray. He meets age criteria and has failed conservative management and a previous arthroscopic treatment.  His knee biomechanics and ligamentous stability is normal. The literature supports the use of this procedure for young patients with these types of lesions as second-line treatment, as they are not good candidates for arthroplasty due to their young age. Long-term results have been shown to be reasonable as far as outcome and durability. There is sufficient quality literature to support this procedure in patients that have failed first-line treatment. Thus, the requested autologous cultured chondrocyte and autologous chondrocyte implantation of the knee are likely to be more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 24-year-old male enrollee has requested reimbursement for mental health inpatient treatment from 8/03/16 through 8/04/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  Premature discharge of patients with severe mental illness and prominent psychosis not only increases patient morbidity and the chances of prompt re-admission, but also exposes the general population to preventable risk of harm.  This patient had an underlying formal thought disorder with violent outbursts at home and recent aggression with homicidal ideation.  On 8/03/16, the patient remained psychotic, anxious and guarded.  He was assessed to have poor insight, judgment and impulse control.  The provider further determined that the patient remained a potential threat to self and others due to his psychotic burden.  After liaising with family and the outpatient psychiatrist, a medication change was made on 8/03/16, and a rather recently released antipsychotic medication, cariprazine, replaced one of the other antipsychotic agents.  In sum, on 8/03/16, the patient was still suffering from the illness burden that prompted the admission.  He was engaged in active treatment during the entire hospital stay, which included evidence-based psychiatric care and communication with family and outpatient providers to promote a seamless transition back to the community.   During the disputed timeframe, the acute inpatient setting was reasonably expected to both improve the patients condition and prevent a more serious episode of illness.  Thus, mental health inpatient treatment from 8/03/16 through 8/04/16 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.