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

Summary Reviewer 

The patient is a 30-year-old male with a history of extensive physical and emotional abuse dating back to childhood and a history of alcohol as well as drug abuse. He was currently not working as a private basketball trainer due to COVID-19 and associated restrictions. The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a.
stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.
In terms of risk of harm, the records support a score of 3. He has been involved in excessive use of substances. There was no suicidal or homicidal ideation.
With regard to functional status, the records support a score of 3. The patient had relationship problems as a result of his drinking. His relationship with his girlfriend had suffered, and there was strain with his mother as well. He was motivated to achieve stability in these relationships and was engaged in family therapy.
In terms of comorbidity, the records support a score of 3. He has insulin dependent diabetes mellitus. There was nothing in the notes to indicate that his blood sugars were unstable.
With regard to level of stress of the recovery environment, the records support a score of 3. He was unable to work due to COVID-19 restrictions and was financially dependent on his mother.
In terms of level of support of the recovery environment, the records support a score of 2. The patientas mother participated in treatment.
With regard to resiliency and treatment history, the records support a score of 3. The patient has had emotional problems since childhood and has struggled with substance use.
In terms of engagement and recovery status, the records support a score of 2. He had acceptance of his illness and was engaged in his treatment. He was motivated to get better.
Thus, the records support a composite score of 19. Intensive outpatient program level of care was medically indicated. Therefore, intensive outpatient program services provided from 7/15/20 through 10/08/20 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 29-year-old female enrollee has requested reimbursement for the polymerase chain reaction (PCR) testing for methylenetetrahydrofolate reductase (MTHFR) and molecular pathology testing performed on 5/26/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for recurrent pregnancy loss. The physician reviewer found that in this case the patient presents with a history of third trimester loss. An appropriate work-up needs to address the potential etiologies of full term unexplained stillbirths including genetic studies, thyroid studies and antiphospholipid antibodies (APLAS). In this case, there does not appear to be a pathology report that suggests that the placenta was infected or that fetus was severely growth restricted, or that the placenta exhibited signs of chronic ischemic, thrombotic abruption, or chronic abruption like event. According to the current American College of Obstetricians and Gynecologists (ACOG) recommendations testing for inherited thrombophilias in women who have experienced recurrent fetal loss or placental abruption is not recommended because it is unclear if anticoagulation therapy reduces recurrence. Accordingly, the PCR testing for MTHFR and molecular pathology testing performed on 5/26/16 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 29-year-old female enrollee has requested reimbursement for the polymerase chain reaction (PCR) testing for methylenetetrahydrofolate reductase (MTHFR) and molecular pathology testing performed on 5/26/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for recurrent pregnancy loss. The physician reviewer found that placental thrombosis due to maternal clotting abnormality has been proposed as a cause of first trimester loss and stillbirth. According to the American College of Obstetricians and Gynecologists (ACOG), prospective cohort studies have found no association between inherited thrombophilias and fetal loss. More specifically, because of the lack of association between either heterozygosity or homozygosity for the MTHFR C677T polymorphism and any negative pregnancy outcomes, screening for MTHFR mutation analyses is not recommended (Robertson, et al). For these reasons, the PCR testing for MTHFR and molecular pathology testing performed on 5/26/16 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 29-year-old female enrollee has requested reimbursement for the polymerase chain reaction (PCR) testing for methylenetetrahydrofolate reductase (MTHFR) and molecular pathology testing performed on 5/26/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for recurrent pregnancy loss. The physician reviewer found that inherited thrombophilias as cause for late term fetal demise have not been well demonstrated in the peer-reviewed medical literature. The American College of Obstetricians and Gynecologists (ACOG) does not support evaluating patients for a mutation in the MTHFR gene as a cause of fetal demise. Thus, the PCR testing for MTHFR and molecular pathology testing performed on 5/26/16 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 55-year-old female enrollee has requested authorization and coverage for anterior lumbar interbody fusion (ALIF) of the fourth lumbar spine bone through the first sacral bone (L4-L5, L5-S1 ALIF). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who is diagnosed with spondylolisthesis. The physician reviewer found that the medical literature supports the medical necessity for the requested services in this clinical setting. Anterior lumbar interbody fusion is a widely recognized surgical technique for degenerative pathology of the lumbar spine.  Anterior lumbar interbody fusion is recommended as an option for degenerative spondylolisthesis with instability and scoliosis as in this case. Among the various indications, spondylolisthesis with instability and scoliosis remain well accepted indications.  In this case, with type I Modic changes in the intervertebral disc, a reduction in the pain level is to be expected.  There is also evidence of instability and scoliosis, all of which are likely to be benefited by this surgery.  As such, the literature supports the medical necessity of anterior lumbar interbody fusion as requested at L3-4 and L4-5 levels above the congenitally fused L5-S1 level. Therefore, the anterior lumbar interbody fusion of the fourth lumbar spine bone through the first sacral bone (L4-L5, L5-S1 ALIF) is medically necessary for treatment of this patients medical condition. Therefore, for the reasons stated above, the requested services 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 


A 53-year-old male enrollee has requested authorization and coverage for placement of a hypoglossal nerve stimulation device.  The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested device.  A review of the literature indicates that hypoglossal nerve stimulation for treatment of obstructive sleep apnea can show positive and beneficial outcomes with minimal adverse effect in select patients.  However, further independent outcomes data, especially regarding long-term effects, are needed.  The medical necessity of hypoglossal nerve stimulation has not been demonstrated, as there is a lack of data to date to support its efficacy in the longer term.  All told, the requested placement of a hypoglossal nerve stimulation device is not medically indicated for the treatment of this patient.  Therefore, the requested device is 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 

The patient is a 57-year-old female with a history of chronic neck pain with right-sided radicular manifestations in the hand with intrinsic atrophy. Electromyography and nerve conduction studies have revealed C7 radiculopathy consistent with the clinical picture. The physician reviewer found that Cervical disc arthroplasty has become an acceptable and better procedure than anterior cervical discectomy and fusion for a significant patient population with cervical radiculopathy secondary to degenerative changes in the cervical spine, as in this case. Two-level total disc replacement with the U.S. Food and Drug Administration (FDA) approved Mobi-C device demonstrated excellent long-term results with lesser incidence of adjacent level disease, less pain, lesser incidence of revision surgery, and better motion compared to anterior cervical discectomy and fusion for treatment of symptomatic cervical two-level degenerative disc disease. Per the literature, this procedure is safe and effective. A hybrid construct is another option with a fusion at C7-T1 and total disc replacement at C6-7. There is sufficient support for the requested services in this clinical setting. Therefore, the requested cervical spine surgery is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 17-year-old male enrollee has requested reimbursement for the mental health inpatient services provided from 5/31/18 through 6/6/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found that according to the American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII), the mental health inpatient services provided from 5/31/18 through 6/6/18 were medically necessary. Per the documentation dated 5/31/18, the patient remained symptomatic. He was noted to be isolative and functioning below the level of his peers. He continued to endorse grandiose delusions, had disorganized thought process, as well as poor insight and judgment. Based on the documented history and clinical status, the patient met CASII service intensity criteria for secure 24-hour service with psychiatric management for the dates of service at issue. Moreover, the current medical literature supports that the continued services were medically necessary (Gray and Squeglia; Starzer, et al). Therefore, the mental health inpatient services provided from 5/31/18 through 6/6/18 were medically necessary for treatment of this patients behavioral health issues. Based on the foregoing discussion, 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 54-year-old male enrollee has requested authorization and coverage for Androgel. 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 low testosterone can lead to such complications as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue. For these reasons, many providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dL.  The general target level for testosterone ranges from 350 to 750 ng/dL, which is roughly the range for healthy, androgen-sufficient adult men. Testosterone levels should be monitored three to six months after initiation of treatment in order to assure that the patients testosterone level is optimal, and the dose of testosterone replacement therapy should be adjusted accordingly. The medical evidence supports the requested medication in this clinical setting. Therefore, AndroGel is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 58-year-old female enrollee has requested reimbursement for anesthesia services provided on 6/14/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for treatment of the enrollee, who underwent a colonoscopy. The physician reviewer found the submitted documentation demonstrates the medical necessity of the services at issue in this clinical setting. This patient received propofol for sedation. The U.S. Food and Drug Administration package insert for propofol specifically states monitored anesthesia care, propofol should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure". Therefore, the presence of a separate provider for anesthesia is required. The current medical evidence supports the services at issue in this clinical setting. All told, anesthesia services provided on 6/14/17 were 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

The patient is a 58-year-old male with a history of uveal melanoma. A tumor sample was submitted for genetic testing with the DecisionDx-UM analysis. The patient has requested reimbursement for the DecisionDx-UM test provided on 8/14/17. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary. DecisionDx-UM is a test that analyzes the genetic profile of a uveal melanoma tumor sample to determine its risk for metastasis. The DecisionDx-UM test stratifies a tumor to low risk and high risk for metastasis. Based on the available medical literature, the DecisionDx-UM is now considered within the standard of care for patients with uveal melanoma. Clinically, it helps determine how intensely a patient needs to be monitored for metastasis. Given these findings, the DecisionDx-UM test provided on 8/14/17 was medically necessary for evaluation of this patients uveal melanoma.  Based on the foregoing discussion, the testing at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 38-year-old female enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation provided from 10/04/19 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. This patients depression is treatment-resistant. Multiple antidepressants and augmentation strategies have not successfully brought on remission. George and colleagues showed that transcranial magnetic stimulation was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Avery and colleagues provided evidence that transcranial magnetic stimulation is a safe and effective treatment for major depressive disorder. Connolly and colleagues reported that transcranial magnetic stimulation was found to be safe and effective in both acute and maintenance treatment of patients with treatment-resistant depression. Transcranial magnetic stimulation is an effective treatment. It has been approved by the U.S. Food and Drug Administration for the treatment of patients with treatment-resistant major depressive disorder and is consistent with standards of good medical practice. Therefore, transcranial magnetic stimulation is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 58-year-old male has requested authorization and coverage for proton beam therapy (77499). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees right tonsillar cancer. The physician reviewer found that the use of proton beam therapy is an accepted radiation technology that has proven efficacy and tolerability. Certain conditions, such as base of skull chordomas and chondrosarcomas and pediatric central nervous system malignancies, are probably best treated with proton therapy, due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue. Data on proton beam therapy for oropharyngeal cancers are scant. Likewise, scant data compare outcomes with proton beam therapy versus intensity modulated radiation therapy. While preliminary dosimetric data suggests that proton beam therapy may be better at sparing pharyngeal constrictor muscles, spinal cord, parotid glands, larynx, and brainstem, whether dose reduction to any of these structures (beyond what intensity modulated radiation therapy can achieve) results in any benefit in clinical outcome is unknown. For most head and neck cancers, intensity modulated radiation therapy should also be able to readily spare the salivary glands, pharyngeal constrictors, spinal cord, brainstem, mandible and other normal tissues. In this patients case, there is a lack of documentation that intensity modulated radiation therapy would result in an unacceptable plan. The case records do not adequately demonstrate the need for proton therapy using dosimetric evidence. A plan comparison was provided, but it is not evident that the proton beam radiation plan results in clinically meaningful reduction in any normal tissue. All told, the requested proton beam therapy is not likely to be superior over other available treatment options. Based upon the information set forth above, the requested services are 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

A 58-year-old male has requested authorization and coverage for proton beam therapy (77499). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees right tonsillar cancer.The physician reviewer found that based on the submitted documentation, the requested proton beam therapy is not likely to be more beneficial photon-based intensity modulated radiation therapy for the treatment of the above patients tonsillar cancer. Compared to standard radiotherapy with photon intensity modulated radiation therapy, the benefit of proton beam therapy is that radiation dose is deposited more precisely on its target. This translates into a decrease in exposure of normal tissue in the low-dose to intermediate-dose range, but not in the high-dose range. Comparing dosimetric parameters, proton beam therapy will also appear superior than photon-based intensity modulated radiation therapy. However, this dosimetric benefit does not always translate into an actual clinical benefit to the patient. In this patients case, a comparison chart was submitted for proton beam therapy versus intensity modulated radiation therapy, and this showed decreased doses to the spinal cord, brainstem, lips, contralateral parotid gland, and esophagus with proton beam therapy. However, the doses listed for the intensity modulated radiation therapy plan were already under normal tissue tolerance. Thus, the dosimetric improvement with proton beam therapy is not likely to be clinically significant. In sum, the requested proton beam therapy (77499) is not likely to be more effective than other available treatment options. Based upon the information set forth above, the requested services are 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
A 58-year-old male has requested authorization and coverage for proton beam therapy (77499). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees right tonsillar cancer. The physician reviewer found that currently, there is a lack of clinical data in the medical literature to suggest that treatment with proton beam therapy offers a clinical benefit compared to conventional radiation therapy techniques for tumors of the head and neck area. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy. A recent comparative analysis by Sio and colleagues found no significant difference in symptom burden in the acute and chronic phases of treatment with proton beam therapy when compared to photon therapy for head and neck cancer. Consensus group guidelines do not support the use of proton therapy in this setting. There is a lack of level I evidence to support the use of proton therapy for the treatment of head and neck cancer. Thus, the superior efficacy of the requested proton beam therapy (77499) has not been established in this patients case. Based upon the information set forth above, the requested services are 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.