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

Summary Reviewer 2


A 21-year-old female enrollee has requested reimbursement for the outpatient papanicolaou smear testing performed on 7/17/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees abnormal and showed atypical squamous cell of undetermined significance (ASC-US) and high risk human papilloma virus (HPV) test.   The physician reviewer found that although the patients cervical cancer screening began earlier than typically recommended due to a sexual assault, the provider in this case is following the established guidelines for follow-up of an ASC-US and HPV positive Pap smear in a 21-year-old.  The appropriate follow-up included the repeat Pap smear that was done on 7/17/15 given the previous abnormal findings on the Pap smear performed in 2014. For these reasons, the Pap smear performed on 7/17/15 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 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 3


A 21-year-old female enrollee has requested reimbursement for the outpatient papanicolaou smear testing performed on 7/17/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees abnormal and showed atypical squamous cell of undetermined significance (ASC-US) and high risk human papilloma virus (HPV) test.   The physician reviewer found that by 2001, revised Bethesda system terminology for reporting cervical cytology results and the availability of findings from a recent randomized trial of strategies for managing minor cervical cytologic abnormalities had created the need for a standard approach to managing women with abnormal cervical cytology and cervical cancer precursors. In response, the American Society of Colposcopy and Cervical Pathology (ASCCP) initiated a process that developed comprehensive, evidence-based consensus guidelines to aid providers in managing patients with abnormal cervical cytology, cervical intraepithelial neoplasia and adenocarcinoma in situ. The ASCCP guidelines are supported by the American College of Obstetricians and Gynecologists (ACOG), which substantially changed both the interval of screening based upon age as well as the actual management of abnormal Pap smears in clinical practice. For a patient with an ASC-US Pap and a positive HPV cotest, the management per the guideline algorithm is repeat cytology at 12 months without HPV cotesting. Thus, the repeat Pap smear performed on 7/17/15 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 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 Overturned

Summary Reviewer 


The parent of a five-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 30 hours per week of applied behavioral analysis (ABA) therapy provided from 6/5/15 through 12/3/15. 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 autism spectrum disorder (ASD). The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. Reichow and colleagues performed a review showing that early intensive behavioral intervention is effective to increase IQ, improve communication and adaptive skills. Based on the documentation submitted for review, the patient presents with symptoms consistent with autism. Maladaptive behaviors including aggression and tantrums are difficult to treat with other interventions. The research shows that although medications including Risperdal can reduce some of the aggression in children with ASD it does not treat the core symptoms and does not provide long term benefits. Matson and Jang performed a literature review on treating aggression in persons with ASD and found that the most effective interventions were behavioral interventions including ABA therapy. Based on the support in the peer-reviewed literature and the documented regression in behaviors with a reduction of hours, the request for 30 hours per week of ABA was and is medically necessary for treatment of the patients medical condition. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 74-year-old male with a history of recent treatment for Streptococcus sanguinis endocarditis (ending on 11/25/20) and a recent resection of a colon cancer.  The patient has requested reimbursement for admission and hospital stay from 12/05/20 through 12/10/20. 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 fails to demonstrate the medical necessity of the services at issue. The records do not demonstrate evidence of serious complications of possible sepsis. The patient did not have a fever, confusion, renal failure or positive blood cultures.  Evaluation on observation status would have been appropriate, and he did not need full hospital admission. Therefore, admission and hospital stay from 12/05/20 through 12/10/20 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 36-year-old female enrollee has requested authorization and coverage for Qsymia. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees diabetes mellitus, hyperlipidemia. The physician reviewer found that obesity is recognized as a major risk factor for type 1 diabetes. In the peer-reviewed medical literature, data suggests that clinically meaningful weight loss, defined as greater than 5%, can lead to improved glycemic control in patients with type 2 diabetes. Moreover, this weight loss is likely to aid in the management of other comorbid conditions (Rejeski, et al). Qsymia is a medication that promotes weight loss and has been shown to improve other health parameters of obese patients, including type 2 diabetes (Mahgerefteh, et al). Given this support, the requested Qsymia is medically necessary for this patient. Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 20-year-old male enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation therapy from 6/30/16 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 conditions.  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Documents critical to the review, such as a psychiatric assessment, interpretative summary, serial progress notes, longitudinal history of the illness burden and outcomes of specific evidence-based psychotherapies and non-pharmacologic interventions, were not presented.  The information provided, including the patients lengthy course of treatment with mood stabilizing and antipsychotic medications and poor tolerability of antidepressants, strongly suggests bipolar depression rather than a unilateral mood disorder and does not detail the influence of the patients psychiatric comorbid conditions.  Considering transcranial magnetic stimulation is indicated for the acute phase treatment of major depressive disorder at this time, and the safety and effectiveness of transcranial magnetic stimulation therapy has not been established for other psychiatric disorders, the medical necessity of the services at issue cannot be established.  All told, transcranial magnetic stimulation therapy from 6/30/16 forward was not and is not medically indicated for the treatment of this patient.  Therefore, 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 39-year-old male enrollee has requested reimbursement for inpatient services from 4/30/17 through 5/4/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees dermatofibrosarcoma protuberans (DFSP) of the left shoulder. The physician reviewer found that the optimal outcome for application of a split thickness skin graft to a wound is 100% engraftment. Multiple studies have shown that the application of a wound VAC facilitates the skin graft take, thereby reducing the incidence of graft loss and the subsequent events of: 1) potential infection, 2) additional wound care, 3) possible repeated operations to apply additional skin grafts. In addition, immobilization of the engrafted area reduces shear forces and increases the rate and overall percentage of successful skin grafts. While VAC therapy can be used in the outpatient setting, given the irregular contour of the shoulder and the ongoing need to assess and maintain the negative pressure to ensure optimal function of the VAC device, inpatient care is the optimal setting for continuous VAC device use. Therefore, given the location of the tissue defect on the left shoulder and the inherent immobility required, as well as the indicated use of a wound VAC, inpatient care for the provision of these services was medically indicated. Therefore, the inpatient services provided from 4/30/17 through 5/4/17 were medically necessary for the treatment of this patients medical condition. In sum, based on the reasons stated above, the services at issue were medically necessary for the treatment of this patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 33-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) testing provided on 5/30/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of enlarged lymph nodes. The physician reviewer found there is a lack of support in the medical literature for the services at issue in this clinical setting. The medical literature indicates that Epstein-Barr virus (EBV) is the main etiology of infectious mononucleosis syndrome associated with lymphadenopathy. The main methods of evaluation include PCR testing and testing by ELISA for the viral capsid antigen. Quantitative PCR testing may be indicated for the following EBV evaluations: EBV viral load, to monitor for EBV viral replication in hematopoietic stem cell and solid organ transplant recipients. More frequent testing is worth considering if the EBV load is rising. However, for standard risk individuals, as this patient, testing should be done only when they are suspected to have EBV infection. The submitted documentation does not support that this patient had a medical indication to have warranted the PCR testing. Accordingly, PCR testing provided on 5/30/17 was not likely to have been of greater benefit than the standard therapy available for evaluating this patients medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been 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 33-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) testing provided on 5/30/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of enlarged lymph nodes. The physician reviewer found that the patient has had a history of enlarged lymph nodes of unknown etiology. She has had a biopsy and blood tests, which were all negative. She had a PCR test Epstein-Barr virus and other organisms. The common testing performed for lymphadenopathy can generally determine the cause of the lymphadenopathy. The test results for this patient were normal but she continued to have large lymph nodes. A PCR test to detect the cause of the lymphadenopathy is within the standard of care to evaluate uncommon etiologies of large lymph nodes such as in this patients case when all standard first step work up have been negative. As such, PCR testing provided on 5/30/17 was likely to have been more effective than the available standard techniques for the evaluation of this patients medical condition. Therefore, for the reasons stated above, the services at issue were likely to have been 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 Upheld

Summary Reviewer 3

A 33-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) testing provided on 5/30/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of enlarged lymph nodes. The physician reviewer found that the Epstein-Barr virus is the main etiology of infectious mononucleosis (IM) syndrome that is characterized by fever, sore throat, and lymph adenopathy. Since this virus could be associated with a number of malignancies, some hematologic disorders, and chronic fatigue syndrome, identification of IM is of importance.  The majority of the human adult population is infected with EBV. Usually the infection is well tolerated without any further symptoms after primary infection. In some patients with infectious mononucleosis, or in some who had an infection in their past, it may be important to diagnose symptomatic disease or differentiate infectious mononucleosis from other conditions. In these cases, serological methods, i.e., immunofluorescence, ELISA, or Western blot, are the methods of choice to come to an unequivocal diagnostic conclusion, while the detection and quantification of viral DNA through PCR plays a minor role. ELISA could be applied as a first and preliminary diagnostic test for IM. In addition, this test could be applied in various phases of the disease with a higher sensitivity comparing to PCR. In individuals where EBV infection is associated or causally linked with autoimmune or malignant disease or in patients who have been bone marrow or solid organ transplanted, or in patients with severe immune-suppression, prolonged EBV primary infection or EBV reactivation from latency may be a serious and life-threatening complication. As such, determining the serostatus correctly is important for these patients. However, in this patients case, there was no documentation that this patient had immunosuppression or that she was a transplant patient. In sum, for this patient who presented with lymphadenopathy of unknown origin, PCR testing provided on 5/30/17, was not likely to have been superior over other standard methods of evaluating her medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been 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 1

A 52-year-old male enrollee has requested reimbursement and prospective authorization and coverage for elotuzumab (Empliciti) from 1/4/17 through 7/3/17. The Health Insurer has denied this request indicating that the medication at issue was and is considered investigational for treatment of the enrollees myeloma. The physician reviewer found that Empliciti is a monoclonal antibody targeted on a glycoprotein present on myeloma cells. Empliciti has been approved by the U.S. Food and Drug Administration (FDA) for use with lenalidomide and dexamethasone (Gormley, et al). There are currently multiple studies exploring the usefulness of this drug in various combinations and at different stages in the treatment of myeloma. However, there is a lack of data that adding Empliciti to this patients treatment as part of a clinical trial is likely to be more beneficial than participation in the clinical trial without Empliciti. The patient has already been treated with Empliciti with progression of the disease. Therefore, treatment with Empliciti from 1/4/17 through 7/3/17 was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the medication at issue was not and 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 2

A 52-year-old male enrollee has requested reimbursement and prospective authorization and coverage for elotuzumab (Empliciti) from 1/4/17 through 7/3/17. The Health Insurer has denied this request indicating that the medication at issue was and is considered investigational for treatment of the enrollees myeloma. The physician reviewer found that Empliciti is a humanized monoclonal antibody against SLAMF7, which is expressed on most myeloma cells. Empliciti was approved by the U.S. Food and Drug Administration (FDA) in 2015 for use in patients with relapsed and refractory myeloma in combination with lenalidomide and dexamethasone. This patient received Empliciti as part of a clinical trial. At the time of this patients enrollment, there was already compelling data on the efficacy of Empliciti in patients with myeloma (Lonial; et al; Zonder, et al). Given this support, the requested treatment with Empliciti from 1/4/17 through 7/3/17 was and is 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 medication at issue was and 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 3

A 52-year-old male enrollee has requested reimbursement and prospective authorization and coverage for elotuzumab (Empliciti) from 1/4/17 through 7/3/17. The Health Insurer has denied this request indicating that the medication at issue was and is considered investigational for treatment of the enrollees myeloma. The physician reviewer found that there is no dispute that pomalidomide with Empliciti and Decadron is not a compendia or literature supported regimen. As the patient has responded to Empliciti with pomalidomide and Decadron, per the National Comprehensive Cancer Network (NCCN) compendium, the continued use of Empliciti in combination with the proposed clinical trial was and is 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 medication at issue was and 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 61-year-old female enrollee has requested authorization and coverage for Trilogy 100 noninvasive ventilator. The Health Insurer has denied this request and reported that the requested device is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the requested device in this clinical setting. Amyotrophic lateral sclerosis is a progressive neurodegenerative condition that can affect all muscles of the body, including the diaphragm. This can result in significant difficulty with breathing. The use of non-invasive mechanic ventilation has shown a survival benefit. The use of such device has become the standard of care in the management of the symptoms of amyotrophic lateral sclerosis. Therefore, the requested Trilogy 100 non-invasive ventilator is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 63-year-old male enrollee has requested reimbursement for monitored anesthesia care provided on 10/21/19. 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 this patient does not have any documented significant disease history. The request is for reimbursement for monitored anesthesia care during routine screening colonoscopy with polypectomy. According to the American Society of Anesthesiologists guideline for anesthesia care during endoscopic procedures, monitored anesthesia care is warranted in prolonged or painful procedures such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that monitored anesthesia care is more likely necessary in patients with a failed history of moderate sedation for the procedure or psychological impediments to cooperation. The provided records do not support any of these criteria, or other criteria in the literature, such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, age greater than 70, pregnancy, increased aspiration risk, American Society of Anesthesiologists class III or higher, or morbid obesity. According to the most recent guidelines from the American Society for Gastrointestinal Endoscopy, during endoscopic procedures (unlike surgery) consciousness during the procedure is acceptable and is the goal during most procedures, and monitored anesthesia care is recommended for prolonged procedures requiring deep sedation, previously anticipated intolerance to standard sedatives, American Society of Anesthesiologists class IV or V, or risk for airway obstruction due to anatomic variant. For these reasons, the submitted records do not support the medical necessity of monitored anesthesia care in this case. Therefore, monitored anesthesia care provided on 10/21/19 was not medically necessary for the treatment of this patient.