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

Summary Reviewer 2


A 33-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 2/18/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees small bowel Crohns disease. The physician reviewer found in this case, Anser IFX was ordered to determine infliximab level and whether antibodies to infliximab were present. The use of Anser IFX to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have clear infliximab levels been established (Steenholdt, et al). Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response (Vande Casteele, et al; Nanda, et al). A recent study concluded that prospective evaluation of the value of measuring serum concentrations of infliximab should be performed before these data can be included in patient management strategies (Adedokun, et al). One study, with some patients undergoing dose intensification following initial non-response, showed no difference in serum levels of infliximab between patients who responded to dose intensification versus those who did not (Pariente, et al). Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing (Vande Casteele, et al). A systematic review reported that future prospective controlled studies are needed, especially considering that anti-tumor necrosis factor (TNF) levels are influenced by several variables that can fluctuate over time and among individuals (Yarur, et al). For these reasons, the Anser IFX testing performed on 2/18/16 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 33-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 2/18/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees small bowel Crohns disease. The physician reviewer found antidrugs antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear. There is a lack of well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al). In addition, the clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Moreover, it has not been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. In this case, the patient showed good clinical response to Remicade, and no change were made to her Remicade dosing regardless of Anser findings. Thus, the Anser IFX testing performed on 2/18/16 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 58-year-old female enrollee has requested reimbursement and prospective authorization and coverage for chemical dependency residential treatment services provided from 10/29/18 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 post-traumatic stress disorder (PTSD). The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. On 1/02/19, the patients mood had improved. She had slept well. On this date, therapy continued delving into her history of sexual trauma. The records noted the connection between childhood sexual trauma and substance use. Based on the clinical notes, the patient remained at risk of relapse. Patients conditions wax and wane. A relatively positive documentation on one day does not indicate spontaneous cure. Rather, this denotes progress and that the treatment is working, which is an indication to continue treatment. The American Psychiatric Association treatment guidelines note that residential treatment or similar care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. This patient requires a safe and stable living environment in order to develop her recovery skills. The purpose of detoxification is to make the patient physically stable and safe. Rehabilitation is an essential component that should follow detoxification to help the patient maintain sobriety and reduce risk of relapse. Given the severity of the patients illness and need for detoxification as well as risk factors such as trauma history, residential treatment was and is in accordance with generally accepted standards of medical practice. The current medical evidence supports the services at issue in this clinical setting. Therefore, chemical dependency residential treatment provided from 10/29/18 forward was and is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 51-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 5/23/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who reported bilateral breast tenderness. The physician reviewer found there is sufficient support for the service at issue in this clinical setting.  Skaane and colleagues noted the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues indicated integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  The literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, breast tomosynthesis performed on 5/23/16 was likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the service 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 overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 51-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 5/23/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who reported bilateral breast tenderness. The physician reviewer found that tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her mammogram been done with two-dimensional imaging alone.  Based upon the information set forth above, the service 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 overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 51-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 5/23/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who reported bilateral breast tenderness. The physician reviewer found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  There is a lack of support for breast tomosynthesis in patients case.  Generally, bilateral breast tenderness is an unlikely presenting symptom for breast cancer.  In addition, she did not have particularly dense breasts, and her mammogram was unchanged when compared to a prior mammogram.  Breast tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to prior mammograms.  Thus, breast tomosynthesis performed on 5/23/16 was not likely to have been of greater benefit than other available modalities.  Based upon the information set forth above, the service 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 Upheld

Summaryi
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The parent of a 16-year-old male has requested authorization and coverage for Norditropin injections 30/3 ml. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrolleei12s medical condition. The physician reviewer found that guidelines recommend the use of growth hormone therapy for idiopathic short stature when height is 2.2 standard deviation below the mean for age and sex. This patienti12s height was 1.88 standard deviations below the mean and did not meet the definition of idiopathic short stature. He had a bone age that was delayed approximately two years. The exact height of the patient and the estimated predicted height based on this bone age prior to initiation of therapy was not provided. The patient has a history of delayed puberty, which is a cause of short stature. Short stature secondary to delayed puberty can cause temporarily low growth velocity, but the final height is normal, without therapy. Growth hormone therapy is not indicated for the diagnosis of short stature due to delayed puberty. The delayed bone age supports the diagnosis of constitutional delay of growth. The Tanner stage (puberty assessment) of the patient before the initiation of growth hormone therapy is not provided. The growth velocity without information regarding the puberty stage can be misleading. The growth velocity is noted as 2 cm per year, although the growth chart does not support this. Growth velocities that are not extrapolated from the last 12 months might be inaccurate due to short intervals of measurements. The patient had a good response to growth hormone therapy. However, a child with constitutional delay of puberty would catch up anyway, as puberty would advance the growth velocity. The medical evidence does not support the requested medication in this clinical setting. Therefore, Norditropin is not 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 female enrollee has requested reimbursement for residential treatment center services provided from 10/16/15 through 5/31/16. 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 RTC services provided from 10/16/15 through 5/31/16 was medically necessary for treatment of the patients medical condition. Based on the documentation provided for review, the stress of the patients family was continuing to trigger most of her symptoms, including depression, suicidal thoughts, disordered eating pattern and PTSD. It was an essential component of this patients therapy that she be removed from the home and provided a safe, structured and supportive environment 24-hours per day. Only by being removed from the home could she begin to work on her own issues in individual and group therapy. During this time, family therapy continued allowing her to very slowly develop a relationship with her parent, with whom she would live after discharge. Given the above, the services at issue were medically necessary for treatment of the patients medical condition. 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 Upheld

Summary Reviewer 


A 58-year-old male enrollee has requested reimbursement for Synvisc injection performed on 7/06/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees degenerative joint disease of the knee. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The current medical evidence does not support the services at issue in this clinical setting.  There have been carefully conducted double-blinded studies which do not document any clinical effect from hyaluronan injection.  This patient has had multiple injections and with each injection and each exposure to the antigen, there is an increased risk of allergic response.  There is also a risk of iatrogenic infection being introduced into the joint during the process of injection.  Rutjes and colleagues performed a meta-analysis of the efficacy of viscosupplementation.  The authors concluded after review of a total of 89 trials involving 12,667 adults that in patients with knee osteoarthritis viscosupplementation is associated with a small and clinically irrelevant benefit and there is an increased risk of serious adverse effects.  All told, Synvisc injection performed on 7/06/15 was not medically indicated for the treatment of this patient.  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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of an 11-year-old male enrollee has requested reimbursement and prospective authorization and coverage for applied behavioral analysis therapy from 7/18/18 forward (H0031, one hour per month, H0032, four hours per month, H2012, four hours per week school, H2012, two hours per week home, H2012, two hours per week parent training, H2019, four hours per week school board certified assistant behavior analyst (BCaBA), H2019, four hours per week home/community BCaBA, H2019, 12 hours per week school, and H2019, 20 hours per week home/community). 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. The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue. The ABA provider has indicated that the patients problem behavior (i.e., aggression, tantrums) is reportedly occurring at home, in the community, and at school. However, there is a lack of data on the severity of problem behavior at school, just anecdotal reports. Before approval of the codes H2019 and H2012 in school, it is important to first evaluate the need for these services. The BACB Autism Practice Guidelines indicate that treatment should be dictated by assessment which, in turn, informs treatment intensity. Per the medical evidence, ABA is the most evidence based treatment for children on the autism spectrum. Based on the records, H0031, one hour per month, H0032, four hours per month, H2012, two hours per week home, H2012, two hours per week parent training, H2019, four hours per week home/community BCaBA and H2019, 20 hours per week home/community are medically necessary for the treatment of this patient. However, the submitted documentation fails to demonstrate the medical necessity of H2012, four hours per week school, H2019, four hours per week school BCaBA, and H2019, 12 hours per week school. Therefore, a portion of the services at issue was and is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The patient is a 41-year-old male who was involved in a motor vehicle accident in 2002, which resulted in a left brachial plexus injury. There has been residual severe left arm weakness distal to the shoulder despite extensive treatment including nerve transfers in 2003 and 2005, static orthoses and physical therapy.  He has been effectively one handed functionally. A myoelectric elbow-wrist-hand orthosis has been recommended for promotion of bimanual activities and protection of the sound contralateral upper limb from overuse syndrome. The patient has requested authorization and coverage for MyoPro device. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of this patients medical condition. The medical literature regarding the potential benefit from this type of device is limited to preclinical work, developmental work and small anecdotal reports. The requested device is not yet proven to provide functional improvements that could not be achieved through standard occupational therapy interventions with static orthoses and durable medical device used for assisting with self care and other activities.  It is not well known whether users will adopt the device for regular functional use in the long term or if the device itself causes injuries with long term use (e.g., at the shoulder due to the equipments weight). Current commercially available iterations of this type of device remain heavy, bulky, difficult to wear, and difficult to use on a practical basis.  Further study is required to determine its efficacy and safety when compared to standard means of treatment.  As such, the requested device is not reasonably expected to favorably affect this patients clinical or functional outcomes. Therefore, the MyoPro device is not likely to be more effective than the standard therapies available for the treatment of this patients medical condition.  Based upon the information set forth above, the requested device 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 Upheld

Summary Reviewer 2

The patient is a 41-year-old male with a history of motor vehicle accident in 2002 with multiple fractures and left brachial plexopathy. He underwent multiple attempts at nerve transfer in 2003 and 2005. He also underwent extensive physical and occupational therapy. The left arm is nonfunctional and is described as flail distal to the shoulder. The patient has requested authorization and coverage for a MyoPro device. The Health Insurer has denied this request on the basis that the requested device is investigational for the treatment of this patients left brachial plexopathy. There is minimal evidence in the medical literature that this orthosis would be helpful in this clinical setting. There are a few studies showing the myoelectric orthosis can be beneficial when applied to patients with upper motor neuron pathology such as stroke. However, this patient has a brachial plexus lesion with monoplegia and it is undetermined whether a myoelectric device would be of benefit in the long run with such a severe lower motor neuron injury. In this patients case, there is a lack of evidenced based literature supporting the efficacy of the requested device. In sum, MyoPro device is not likely to be of greater benefit over the available standard method of treating this patients medical condition.  Based upon the information set forth above, the requested device 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 Upheld

Summary Reviewer 3

The patient is a 41-year-old male who sustained a left brachial plexus injury in 2002 and has been noted to have severe distal loss of function despite extensive rehabilitation as well as attempts at surgical reconstruction. A myoelectric orthosis has been proposed in this case. The patient has requested authorization and coverage for a MyoPro device. The Health Insurer has denied this request noting that the requested device is investigational for the treatment of this patient. There is very limited support in the literature as to the superior effectiveness of the requested device in this patients case. Although there have been numerous articles in the literature supportive of the potential benefits of this treatment, a recent review by Nadi and Midha discusses the limited available data regarding its effectiveness. The authors conclude that this technology as to its efficacy remains uncertain, Overall, this procedure portends great promise but remains experimental. The future results of the other 11 patients in the study may provide further supporting evidence for the validity of this approach. Conversely, the longer period of follow-up may uncover the downsides of this approach that are still hidden in the shadow of early success. As such, there needs to be further studies before this device can be recommended as a standard option for individuals in this clinical setting. There is still a paucity of evidence in the literature as to its short and long term effectiveness. All told, the requested MyoPro device is not likely to be superior over the standard options available for treating this patients medical condition.  Based upon the information set forth above, the requested device 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.