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

Summary Reviewer 3


A 60-year-old female enrollee has requested reimbursement for Prolia (denosumab) injection administered on 10/20/15. The Health Insurer has denied this request indicating that the medication at issue is considered investigational for treatment of the enrollees osteoporosis. The physician reviewer found Prolia is approved by the Federal Drug and Administration for treatment of postmenopausal osteoporosis. It is anticipated that Atelvia will not provide the benefit of therapy given that the patient has poor absorption and her bone density has not improved in the hip. The patient has severe osteoporosis as documented by a BMD below -3 in both femoral necks and prior peripheral fracture. The patients medical records indicate that she is at a high risk for fracture and studies have shown that Prolia reduces the incidence of vertebral fractures by about 68%, hip fractures by about 40%, and nonvertebral fractures by about 20% over 3 years (Cosman et al). Moreover, the patient was on bisphosphonate (Atelvia) therapy and her BMD did not improve. The patient also has a history of gluten intolerance, which suggests that she might have a malabsorption factor, which makes oral bisphosphonates poorly absorbed and therefore ineffective. For all these reasons, the medication at issue was likely to be of more benefit for treatment of the patients osteoporosis than available standard therapy. Based upon the information set forth above, the medication 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 Upheld

Summary Reviewer 

The patient is a 61-year-old female who presented to her provider on 5/25/21 with a complaint of worsening knee pain. The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left knee. The physician reviewer found that the current medical evidence does not support the requested services in this clinical setting. The incidence of abnormal MRI findings in asymptomatic individuals was established as early as 1992 by Boden and colleagues. The authors noted, aThe high incidence of abnormal MRI findings in asymptomatic subjects underscores the danger of relying on a diagnostic test without careful correlation with clinical signs and symptoms.a In other words, simply obtaining an MRI without correlation with a detailed clinical examination can lead to unnecessary conclusions, and even worse, unnecessary surgery.  For this reason, conservative management, as suggested by the Health Insurer, is certainly worthwhile. In the requisition for the knee MRI, it is stated that the patient has had four weeks of prior physical therapy as well as supervised home exercise program within the prior three months. However, the records do not document this. The submitted documentation does not demonstrate that the patient has completed an appropriate course of conservative management. The records do not document that the patient actually underwent physical therapy. Absent this documentation, the medical necessity of the requested services cannot be established. Therefore, the requested MRI of the left knee is not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

The patient is a 58-year-old female with osteoporosis of the spine demonstrated on a recent dual-energy x-ray absorptiometry (DEXA). She also has history of hypothyroidism, hypercholesterolemia and breast cancer that has been treated with letrozole. Her provider has recommended Prolia. The patient has requested authorization and coverage for Prolia injection. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination.  The submitted documentation supports the medical necessity of the requested medication. This patient has osteoporosis of the spine. Her risk factors include postmenopausal status, treatment with letrozole, an aromatase inhibitor, and vitamin D deficiency. This patient needs to initiate osteoporosis therapy. This patient is on Synthroid, thyroid hormone replacement, which she must take on an empty stomach. This requirement will be affected by the requirement to take alendronate on an empty stomach as well. Additionally, zoledronic acid is frequently associated with a flu-like syndrome post injection, whereas Prolia has rare side effects. Per the medical evidence, Prolia has a better outcome in prevention of spinal fractures as compared to oral bisphosphonates. There is sufficient support for the requested medication in this clinical setting. Thus, the requested Prolia injection is medically necessary for the treatment of this patient. Therefore, 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 48-year-old male enrollee has requested authorization and coverage for intravenous immune globulin (IVIG). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees specific antibody dysfunction. The physician reviewer found the treatment of specific antibody deficiency with replacement immunoglobulin remains controversial. Most experts recommend treatment which includes immunization with conjugated pneumococcal vaccine (Prevnar 7 or 13), aggressive treatment of other conditions predisposing to recurrent sinopulmonary infections, increased vigilance and appropriate antibiotic therapy for infections, prophylactic antibiotics and IVIG. Replacement IGIV is an option for patients with proven recurrent infections that persist after immunizing with conjugate vaccines and appropriate antibiotic treatment (Cohn, et al.). However, studies have demonstrated that prophylactic antibiotic therapy may be as effective as replacement immunoglobulin (Gelfand, et al). In this case, the patient is not on an antihistamine for his elevated IgE and there is no evaluation of his most likely allergic component to his symptoms. The patient has not been vaccinated with the conjugate pneumococcal vaccines. There is also no documentation of a trial of prophylactic antibiotics. Moreover, IVIG is a pooled blood product and there are significant risks involved in the administration of IVIG including thrombosis, renal dysfunction, acute failure and infection. The documentation does not support that IVIG is safe and effective for the patient. In addition, there is no documentation other therapies used and failed such as aggressive allergic rhinitis treatment, vaccinated with conjugate pneumococcal vaccine or trial of prophylactic antibiotics in the patient. Therefore, the request for IVIG is not medically necessary in this clinical setting. For the reasons provided, the 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 Overturned

Summary Reviewer 


A 33-year-old male enrollee has requested authorization and coverage for CPT code 27299 (unlisted procedure, pelvis/hip joint). The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees hip pain. The physician reviewer found that surgical hip dislocation is an established technique for addressing both articular and periarticular pathology associated with painful femoral acetabular impingement. This patient has extensive labral tearing and degeneration including posterior which would be difficult or impossible to treat arthroscopically. Periacetabular osteotomy and labral repair cannot be performed open without dislocating the hip. Thus, dislocation of the femoral head is necessary to access and treat the acetabular sided pathology. Given these findings, the requested CPT code 27299 (unlisted procedure, pelvis/hip joint) is supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested procedure 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 51-year-old male enrollee has requested authorization and coverage for inpatient care. The Health Insurer has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees surgical procedure. The physician reviewer found that infection of a penile implant can cause complications from scarring after the penile implant is removed. Although a few studies with a small numbers of patients have shown that penile implants can be done in an outpatient setting, most providers prefer to continue preoperative antibiotics for at least 24 hours. The American Urological Associations (AUA) guideline for management of erectile dysfunction states, These antibiotics are administered before the incision is made and usually are continued for 24 to 48 hours postoperatively. The AUA best practice statement for antimicrobial prophylaxis in urologic surgery states, Although there are no [randomized controlled trials] RCTs regarding antimicrobial prophylaxis for insertion of penile prostheses, meta-analyses of mesh hernia repair 100 and orthopedic surgery 101 confirm that antimicrobial prophylaxis is beneficial when foreign material is implanted. A prolonged course of antimicrobials has been used by many practitioners following penile prosthesis insertion, but evidence from the orthopedic literature suggests that prophylaxis for 24 hours or less is adequate. In this case, there is a lack of documentation to support the medical necessity for inpatient care. Most patients who undergo penile prosthesis implantation can be discharged within 24 hours of presentation. The patient can be provided with perioperative antibiotics while on observation status without the need for inpatient stay. As such, the request for inpatient admission is not medically necessary for treatment of the patients medical condition. Therefore, the requested service 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 Upheld

Summary Reviewer 

A 57-year-old female enrollee has requested reimbursement for code 81599 (DecisionDx-Melanoma) testing provided on 1/29/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines states while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there are no definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Therefore, code 81599 (DecisionDx-Melanoma) testing provided on 1/29/19 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

The patient is a 42-year-old female with a history of chronic low back pain. The progress notes dated 10/7/17, document a six month history with pain in the lower back radiating into both lower extremities.  Associated symptoms included numbness, tingling and loss of bladder/bowel control.  The pain was reported to be 8 out of 10 and worsening. The patient reported that any level of movement aggravated her low back pain.  Medications for pain relief were not effective.  Other conservative treatments, which have been tried and failed, include chiropractic, physical therapy, topical, and exercise program. On examination, transfers were difficult; range of motion was limited and magnetic resonance imaging (MRI) scan revealed degenerative disc disease at L5-S1 with a 2 mm bulge and possible annular tear on the right. The follow up progress notes document continuing worsening of pain, primarily in the lower back on the right side consistent with the MRI findings of the right side involvement.  The provider discussed treatment options and the patient elected the surgical option in light of the degree of disability.  The provider is recommending anterior lumbar interbody fusion at L5-S1 with anterior instrumentation, L5-S1 cage with interbody fusion with harvest of iliac crest autograft versus bone morphogenic protein. The patient has requested authorization and coverage for autograft spine surgery. The Health Insurer denied this request and reported that the requested services are not medically not necessary. This denial is the subject of this appeal and determination. There is support in the medical literature for the medical necessity of the requested services in this clinical setting. Anterior lumbar interbody fusion is associated with higher success rates compared with posterolateral lumbar fusion in patients with degenerative changes of the lumbar spine including those with instability. There is moderate evidence that for patients with lumbar degenerative disc disease without instability a standalone anterior lumbar interbody fusion has better clinical outcomes than the anterior lumbar interbody fusion plus instrumented open posterior lumbar fusion. With regard to the type of interbody spacer used, the proposed autograft has a high fusion rate. In this case, the patient has severe pain that has not responded to conservative treatment. The patients pain is interfering with her activities of daily living. The provider has documented discogenic origin for the pain.  Based on medical literature and guidelines, the requested anterior lumbar interbody fusion procedure 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 


The parent of a 14-year-old male enrollee has requested reimbursement for residential mental health treatment services provided from 4/25/16 through 12/31/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). The physician reviewer found that the records provided for review do not support the medical necessity of residential mental health treatment services provided from 4/25/16 through 12/31/16 for management of this patients medical condition. There was no evidence that the patient had severe and persistent psychiatric symptoms that results in impairment in multiple settings that require active treatment in a 24-hour supervised setting. Further, there was no evidence of suicidal or homicidal ideations, no evidence of psychosis, and no evidence of physical aggression during this period of time. The documentation suggests the patient could have reasonably been treated at a less intrusive, less invasive level of care such as outpatient treatment. Given these findings, the residential mental health treatment services provided from 4/25/16 through 12/31/16 were not medically necessary. Based on the foregoing discussion, 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 63-year-old male enrollee has requested reimbursement for dopamine transporter imaging with a single proton emission computed tomography (DaT SPECT) scan performed on 8/24/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who presented with persistent hand tremors. The physician reviewer found that there is sufficient support in the medical literature for the services at issue. While a DaT SPECT study is not required for the diagnosis of all patients suspected to have Parkinsons disease, it has been shown to be useful in cases where the diagnosis is not definitive on clinical grounds.  In this particular case, the patients provider suspected Parkinsons disease, although by the history an essential tremor would have been an alternative diagnosis.  It is imperative to provide a definitive diagnosis as treatment for essential tremor and Parkinsons disease are quite different. The treatment options for Parkinsons disease can have significant side effects. This patients diagnosis was determined and verified using this study. As such, an appropriate management approach was initiated. The literature demonstrates the use of this study in differentiating cases of Parkinsons and essential tremor.  An improper diagnosis could have led to suboptimal management and potential exposure to unnecessary side effects. Therefore, DaT SPECT scan performed on 8/24/16 was likely to have been superior to other methods of evaluating this patients medical condition. Based upon the information set forth 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 Overturned

Summary Reviewer 2
A 63-year-old male enrollee has requested reimbursement for dopamine transporter imaging with a single proton emission computed tomography (DaT SPECT) scan performed on 8/24/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who presented with persistent hand tremors. The physician reviewer found that DaT is an acceptable diagnostic technique for the determination of Parkinsons disease. In patients where the cause of tremor is not known or is likely to be caused by other diagnoses, such as essential tremor, the use of a DaT scan can be helpful in determining the correct diagnosis. This scan has been widely used by movement disorders specialists and general neurologists when there is a question of whether a patient has Parkinsons disease. Medical studies have shown that the early diagnosis of Parkinsons disease allows for better control of symptoms and allows the patient to access available resources sooner. Accordingly, this patient benefited significantly from having the scan performed in order to confirm the cause of his tremor. All told, DaT SPECT scan performed on 8/24/16 was likely to have been more effective than other available modalities in evaluating this patient.  Based upon the information set forth 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 Overturned

Summary Reviewer 3A 63-year-old male enrollee has requested reimbursement for dopamine transporter imaging with a single proton emission computed tomography (DaT SPECT) scan performed on 8/24/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who presented with persistent hand tremors. The physician reviewer found that there is a lack of evidence based studies supporting the superior efficacy of the services at issue. The medical literature does not demonstrate that DaT SPECT scan can offer clinical decision making relative to treatment management options in this clinical setting. There remains issues of sensitivity and specificity relative to DaT scans in the diagnosis of Parkinsonian tremor versus other etiologies.  Therefore, in this patients case, DaT SPECT performed on 8/24/16 was not likely to be more efficacious than other standard options for the evaluation of this patient. Based upon the information set forth 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 
The parent of 10-year-old female enrollee has requested authorization and coverage for growth hormone treatment. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees growth hormone deficiency. The physician reviewer found that although combination therapy with GnRH agonist and GH is not recommended for augmentation of height in children with normally timed puberty or in children with idiopathic short stature alone. This patient has a combination of early adrenarche with advanced skeletal maturation at baseline, coupled with true central precocious puberty resulting in rapid acceleration in skeletal maturation and an extremely short adult predicted height.  Her adult height prediction is more than three standard deviations below the mean for age, and her epiphyses are still open. Her skeletal maturation is outpacing her statural growth, resulting in a shorter adult height prediction over time. Based on a recent meta-analysis, evaluating the efficacy and safety of combination therapy with GnRH agonist and GH in children with central precocious puberty, children with combination therapy reached a taller adult height and larger height gains without adverse effects (Liu, et al). As such, GH therapy is medically necessary in this patient to achieve a normal adult height. 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.