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

Summary Reviewer 


The parent of a 14-year-old female enrollee has requested reimbursement for mental health residential treatment center services provided from 11/16/16 through 12/6/16. 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 the mental health residential treatment center services provided from 11/16/16 through 12/6/16 were not medically necessary for treatment of the patients medical condition. According to Mehler, Anorexia nervosa is a psychiatric disorder characterized by abnormal eating behaviors that results in weight loss and has serious potential medical consequences. Most of these complications are readily treatable if diagnosed and attended to early in the course of the illness. Outpatient treatment with modalities such as cognitive behavioral therapy (CBT) can be effective for significantly reducing relapse risk and increasing the likelihood of good outcomes compared with nutritional counseling in the treatment of anorexia nervosa (Bulik, et al). CBT is commonly used on an outpatient basis. Moreover, in most cases outpatient treatment is recommended with hospital admission indicated for those at risk of medical and/or psychological compromise (Hay, et al). In this case, the patient was medically and psychiatrically stable. As of 11/16/16 the patient had stabilized and was eating appropriately. She was at 86% of her ideal body weight. Her medical status was intact and described as psychiatrically stable. She had some laboratory abnormalities that could have been addressed on an outpatient basis and she did not have unstable coexisting health problems. She was not exhibiting severe mood, anxiety or psychotic symptoms and was not engaging in self-harm type behaviors. Based on the clinical documentation submitted for review, the patient could have been treated safely and effectively at a lower level of care as of 11/16/16. 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 Overturned

Summary Reviewer 1

A 60-year-old female enrollee has requested reimbursement for genomic analysis performed on 6/15/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ovarian cancer. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. In order to demonstrate the clinical utility of panel testing for somatic genomic alterations, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with the standard of care. The available literature on clinical utility consists of a small number of uncontrolled studies and nonrandomized controlled trials that use imperfect comparators. This evidence is not sufficient to make conclusions on clinical utility. In addition, there is potential for harm if ineffective therapy is given based on test results. Therefore, genomic analysis performed on 6/15/17 was not likely to have been more effective than other methods of evaluating this patient. 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 2

A 60-year-old female enrollee has requested reimbursement for genomic analysis performed on 6/15/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ovarian cancer. The physician reviewer found that the current medical evidence supports a portion of the services at issue. FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers than can help guide therapy decision making. It has not been determined if molecular markers are useful in treatment determination (predictive markers). There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. Patients who are microsatellite instable (MSI) can be treated with Keytruda. In this patients case, there is support for MLH1, MSH2, MSH6 and PMS2 testing. However, the superior efficacy of the remaining of the services at issue has not been established. Based upon the information set forth above, a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 60-year-old female enrollee has requested reimbursement for genomic analysis performed on 6/15/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ovarian cancer. The physician reviewer found that there are many agents with activity against recurrent ovarian cancer. Thus, treatment off-label is very common. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Von Hoff and colleagues published a study of 86 patients where the progression-free survival on regimen selected by molecular profiling was compared to progression-free on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. The patient is out of standard options and will be offered something off-label. The mutational testing as ordered was medically appropriate. Thus, genomic analysis performed on 6/15/17 was likely to have been of greater benefit than 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 Upheld

Summary Reviewer 1

A 58-year-old female enrollee has requested reimbursement for nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who reported a history of urgency and frequency. The physician reviewer found that there is evidence from randomized trials and prospective observational trials supporting the clinical utility and impact on patient management of percutaneous tibial nerve stimulation in patients with urinary urgency and frequency. However, most trials have a small number of patients with short-term follow-up, and the long-term efficacy of percutaneous tibial nerve stimulation is largely unknown. American Urological Association guidelines recommend behavioral therapies (e.g., bladder training, bladder control strategies, pelvic floor muscle training, and fluid management) as first-line therapy to patients with overactive bladder. Behavioral therapies may be combined with pharmacologic management. Clinicians should offer oral antimuscarinics or oral beta 3 adrenoceptor agonists as second-line therapy. If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti-muscarinic medication, then a dose modification, different anti-muscarinic medication or a beta 3 adrenoceptor agonist may be tried. Botox injection is a standard third-line therapy and is graded better. Percutaneous tibial nerve stimulation has not been proven to be superior to other alternatives. Studies have compared percutaneous tibial nerve stimulation to anticholinergics and have demonstrated comparable efficacy. As such, the superior efficacy of nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18 has not been established. Based upon the information set forth above, the services at issue were 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 female enrollee has requested reimbursement for nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who reported a history of urgency and frequency. The physician reviewer found that the submitted records fail to demonstrate the superior efficacy of the services at issue. The current literature has not established that percutaneous tibial nerve stimulation is of greater benefit than standard methods of treating this patients condition. This patient may benefit from medications, hydrodistention, intravesical therapy and pelvic floor biofeedback. Per the records, first-line and second-line treatments have not been systematically trialed and exhausted. In sum, nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18 was not likely to have been more efficacious than other available treatment options. Based upon the information set forth above, the services at issue were 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 female enrollee has requested reimbursement for nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who reported a history of urgency and frequency. The physician reviewer found that intractable lower urinary tract symptoms and painful bladder/urethral syndrome related to interstitial cystitis can be clinically difficult to treat. Treatment options often are limited and have variable results. Patients often receive multimodal treatment, including proceeding to secondary and tertiary treatment options. Percutaneous tibial nerve stimulation is considered as a tertiary treatment option for intractable lower urinary tract symptoms and painful bladder syndrome with urgency frequency syndrome. There is some support for the requested services in this clinical setting. Therefore, nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18 was likely to have been of greater benefit than other treatment options. Based upon the information set forth above, the services at issue were 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 Upheld

Summary Reviewer 

A 65-year-old female enrollee has requested authorization and coverage for spinal surgery (CPT codes 22212, 63048, 22610, 20931, 63046, 22840, 22842, 22853, 22845, 22556, 22216, 63077, and 22614) and five (5) inpatient days. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees back pain. The physician reviewer found that in the medical literature, Resnick and Groff noted that lumbar fusion is performed for the treatment of painful instability of the spine, usually manifest as chronic low back pain. The documentation available for review does not include evidence of any instability in the thoracic spine. Further, there is no severe stenosis or deformity. The medical records indicate that this patient underwent previous lumbar and cervical fusion surgeries and presents with 50 degrees of kyphosis in the mid-thoracic spine. However, 50 degrees of kyphosis is considered mild in the thoracic spine and does not support the need for fusion. (Chou, et al; Resnick). All told, the requested spinal surgery (CPT codes 22212, 63048, 22610, 20931, 63046, 22840, 22842, 22853, 22845, 22556, 22216, 63077, and 22614) and five (5) inpatient days is not supported as medically necessary for treatment of this patients back pain. Based on the foregoing discussion, he requested services 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 Upheld

Summary Reviewer 

An 18-year-old transgender female enrollee has requested reimbursement for residential mental health treatment for children and adolescents provided from 11/19/17 through 3/08/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. In terms of risk of harm, the records support a score of 1. The medical records indicated that the patient was not actively suicidal. With regards to functional status, the records support a score of 2. The patient had some issues with level of function due to mental illness and relational issues, but overall showed appropriate daily functioning while in treatment. In terms of comorbidity, the records support a score of 1. The patient did not have a history of active serious medical issues or substance use. In terms of level of stress of the recovery environment, the records support a score of 2. The patient was noted to have strained relationship with family and indicated some mild stress at home. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient 
had some outpatient mental health therapy prior to residential admission but continued to have symptoms of anxiety. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy. In terms of acceptance and engagement of the parents, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 15. This score correlates with outpatient services. Therefore, residential mental health treatment from 11/19/17 through 3/08/18 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 20-year-old male enrollee has requested reimbursement for substance use disorder partial hospitalization program (PHP) services provided from 10/3/17 through 10/6/17. 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 the substance use PHP services provided from 10/3/17 through 10/6/17 were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient was not a danger to himself or others, and he was not aggressive or violent. His post-acute withdrawal symptoms were not reported. There were no significant emotional, behavioral, or cognitive symptoms that would warrant continued PHP level of care. There was no high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would have prevented stepping him down to a lower level of care. He was medically and psychiatrically stable. He remained in partial denial about his problem with alcohol. There was no documentation of significant progress, change in medications, and change in treatment plan, or mental status examinations. He had support systems in place. The source of his anxiety and depression were not clear and did not appear to be addressed in the PHP treatments. Thus, the patients continued recovery efforts, and development of coping skills could have been accomplished in IOP level of care or outpatient. He was working on issues in DBT/CBT groups, which could have been provided on an outpatient basis. As such, the services at issue 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 Overturned

Summary Reviewer 1

A 47-year-old female enrollee has requested reimbursement for DecisionDX-UM assay performed on 5/09/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ocular melanoma. The physician reviewer found that the DecisionDX is a study of 15 to 31 genes in a patients melanoma cells.  It has been used to classify the individuals melanoma as having either a high or low risk of metastasis.  It is controversial in cutaneous melanoma as to whether it has additional value when added to the usual pathologic prognostic factors.  However, it is particularly useful in the analysis of uveal melanoma and has been validated in several studies.  Specifically, a Class 1 category carries with it a less than 20% chance of metastasis, whereas Class 2 has a greater than 70% chance of metastasis.  This testing has become a standard in many ocular cancer centers.  Its clinical value lies in determining the need for intense surveillance, and possibly to assist in the decision as to adjuvant therapy.  Therefore, DecisionDX-UM assay performed on 5/09/16 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 47-year-old female enrollee has requested reimbursement for DecisionDX-UM assay performed on 5/09/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ocular melanoma. The physician reviewer found there is sufficient support for DecisionDX-UM assay in this clinical setting.  The testing performed is considered a standard of care in patients with ocular (uveal) melanoma.  This is a rare type of melanoma treated by only a handful of experts.  DecisionDX-UM assay provides prognostic and predictive information to guide adjuvant therapy for patients with uveal melanoma using genomic testing of the tumor.  Thus, DecisionDX-UM assay performed on 5/09/16 was likely to have been more effective than 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 3

A 47-year-old female enrollee has requested reimbursement for DecisionDX-UM assay performed on 5/09/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ocular melanoma. The physician reviewer found that this patient has a rare disease, ocular melanoma, which has a poor prognosis once it metastasizes.  However, knowledge of the propensity for metastasis directly affects surveillance of patients by computed tomography (CT) scan.  Along these lines, two clinical studies have been done using the gene expression classifier Decision DX-UM that defines two classes of ocular melanoma.  Class 1 is associated with a low risk of metastasis and Class 2 has a 50% risk at two years and 72% risk at five years.  There is no other standard prognostic indicator that could serve as an alternative. Thus, the current medical evidence favors the use of this test in the postoperative surveillance of patients with ocular melanoma.  In sum, DecisionDX-UM assay performed on 5/09/16 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The guardian of a 17-year-old male enrollee has requested reimbursement for residential treatment provided from 6/05/14 through 10/11/14. 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.  This patient had a history of substance abuse, truancy, running away, defiance, and risky and self-destructive behavior.  This patient engaged in the therapeutic environment, albeit he was initially resistant to change.  He reportedly showed some progress.  Given this patients level of his behavioral problems, his familys lack of ability to control him, and his defiance of authority, he was not likely to have been receptive to or cooperative with a lower level of care.  Based upon the medical records, this patient could not have effectively been treated at a lower level of care.  He needed long-term treatment for both substance abuse and behavioral health conditions in a restricted environment.  All told, residential treatment provided from 6/05/14 through 10/11/14 was 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.