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

Summary Reviewer 3
A 44-year-old female enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees sacroiliac joint pain. The physician reviewer found that Sacroiliac fusion maybe recommended as a last line of therapy (including either open or minimally invasive procedures) as treatment for sacroiliac joint infection, tumor involving the sacrum, disabling pain due to sacroiliitis due to spondyloarthropathy, or sacroiliac pain due to severe traumatic injury. The procedure may be required for multisegmental spinal constructs (i.e., scoliosis or kyphosis surgery). However, it is not recommended for mechanical low back pain, non-specific low back pain, sacroiliac joint disruption (in the absence of major pelvic fracture), degenerative sacroiliitis, sacroiliac joint osteoarthritis, or sacroiliac joint-mediated pain (other than pain due to etiologies noted above). In this case, the patient has been diagnosed with left sacroiliac joint dysfunction. She has physical examination findings which localize her symptoms to the left sacroiliac joint. However, there are no objective imaging or laboratory findings to indicate the presence of sacroiliac joint infection, tumor, sacroiliitis due to spondyloarthropathy, or post traumatic arthritis. Although North American Spine Society (NASS) does note some evidence supporting sacroiliac fusion for sacroiliac joint mediated pain, the quality of evidence is low. Thus, the requested sacroiliac joint fusion 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 Overturned

Summary Reviewer 1

A 40-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/08/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer that breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  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 overall 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 this patient than had her examination 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 2


A 40-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/08/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found there is sufficient support for the service at issue in this patients case.  Per Skaane and colleagues, 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 noted integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  In sum, digital breast tomosynthesis performed on 9/08/16 was likely to have been more effective than other modalities for 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 3


A 40-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/08/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. 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.  In this patients case, her breasts were described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures better enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis performed on 9/08/16 was likely to have been more efficacious 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 1


A 53-year-old female enrollee has requested authorization and coverage for vascularized lymph node transfer (VLNT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found according to the documentation submitted for review, the patient has a diagnosis of chronic left lower extremity lymphedema that severely affects her function with ambulation and activities of daily living. Her condition is noted to have been partially corrected with suction-assisted lipectomy, but she still had significant lymphedema of the lower part of her leg. She continued with prescribed non-operative management of compression therapy, which has not controlled her condition. Thus, standard recommended therapy has been exhausted and has not been successful. VLNT is a well-recognized form of treatment for lymphedema that has failed conservative management. According to Cheng and colleagues (2013) Vascularized groin lymph node flap transfer using the wrist or elbow as a recipient site is an efficacious approach to treating postmastectomy upper limb lymphedema. Additional peer-reviewed references as cited above document the use of vascularized lymph node transfer as a surgical procedure that is appropriate for the treatment of lymphedema and has a reasonable chance in improving the patients condition. In addition, VLNT is consistent with standards of good medical practice after failure of conservative management which has been well-documented in this case. In addition, there is no evidence that VLNT is being performed for personal comfort or convenience. Given the above, VLNT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 53-year-old female enrollee has requested authorization and coverage for vascularized lymph node transfer (VLNT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the requested procedure is a sophisticated vascularized flap transfer and lymphaticovenous anastomoses with a microsurgical technique. The results documented in the medical literature show a statistically significantly improved functional outcome as a result of the procedure. Moreover, this procedure is specialized and cannot be recommended as routine treatment for all patients. The requested procedure is indicated for well-selected patients, such as in this patient with documented severe lymphedema. In addition, VLNT is likely to yield significant benefits for this patient. Therefore, in this clinical setting VLNT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 53-year-old female enrollee has requested authorization and coverage for vascularized lymph node transfer (VLNT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the patient has a long history of lower extremity lymphedema secondary to treatment for cervical cancer. The patients therapy has consisted of compression devices and a short term of decongestive therapy. This has had significant functional effect on her life as she has been unable to resume her normal physical activity and has had six episodes of lower extremity cellulitis. Vascularized lymph node transfer has demonstrated significant benefit in multiple case series to reduce the extent of lymphedema and increase quality of life. While there is a lack of prospective comparison trials, the results of the multiple single center case series are compelling and are sufficient to demonstrate an anticipated benefit for this patient. Therefore, the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 22-year-old male enrollee has requested reimbursement for partial hospitalization program services provided from 11/2/15 through 12/2/15; and intensive outpatient program services provided on 12/23/15; and outpatient psychiatric group counseling from 12/23/15 through 3/21/15. 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 partial hospitalization program services and intensive outpatient program services during the dates in dispute were not medically indicated for this patient. According to the documentation submitted for review, the patient was not in withdrawals. He did not experience PAWS. He was not a danger to himself or others. He was medically and psychiatrically stable. His medication management could have taken place on an outpatient basis. He was cooperative and motivated. The patient could have been treated at a lower level of care from 11/2/15 through 12/23/15. Outpatient group counseling would have been a sufficient and appropriate level of care for ongoing treatment in conjunction with community based supports such as a 12-step program. Given the above, outpatient psychiatric group counseling from 12/23/15 through 3/21/15 was medically indicated for the treatment of the patients medical condition. Therefore, a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 62-year-old female enrollee has requested authorization and coverage for Repatha SureClick 140 mg/mL. 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 the patient has a cardiomyopathy and a diagnosis of angina, although there is no documentation of testing for coronary artery disease. However, she does have severe hyperlipidemia and a strong family history of early coronary artery disease. In addition, she has been intolerant of multiple statin medications due to recurrent myalgias and also a trial of ezetimibe and bile acid resins which did not get her to LDL goal. Although the extent of established coronary artery disease is not clear, she does carry a diagnosis of angina and is prescribed nitroglycerin for this. In addition, she has severe baseline hyperlipidemia and a trial of statins and multiple other lipid lowering medications has been ineffective or not tolerated due to significant side effects necessitating discontinuation of these medications. There is little chance that lifestyle and dietary modifications would decrease her LDL to less than 100 (goal) without pharmacologic therapy. Since she is multi-statin intolerant and bile acid resins and ezetimibe have been ineffective, her only option is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor. Thus, Repatha is indicated for the treatment of this patient. Therefore, Repatha SureClick 140 mg/mL is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a 14-year-old female enrollee has requested reimbursement for mental health treatment provided from 7/28/16 through 8/10/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  During the dates of service in dispute, the patient was still requiring up to several hours of one-on-one staff time in order to perform routine activities of daily living.  She continued to need prompts for getting up in the morning, going to bed and completing showering and washing her face and hair in an acceptable amount of time.  The amount of staff time she required would not be provided at the partial hospitalization program level of care.  More importantly, she needed treatment in getting out of bed, preparing to shower and other morning hygiene routines.  This patient required staff to be in the bathroom with her, which would not have occurred in a less intensive level of care.  This symptom also had to be addressed, as it was the symptom causing the greatest degree of functional impairment in her life.  All told, for mental health treatment provided from 7/28/16 through 8/10/16 were 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.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 34-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees major depressive disorder. The physician reviewer found that the requested TMS therapy is not medically necessary for treatment of the patients major depressive disorder. TMS is endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population. A typical treatment course of TMS consists of 30 to 40 sessions spanning four to six weeks. According to Perera and colleagues, the standard regimen is treatment courses up to six weeks in duration. The authors stated that Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established. The authors suggest that an extended treatment course of one to two weeks may be appropriate for patients who experience only partial improvement and the clinician believes that a clear plateau of benefit has not been obtained. In this case, the patient started TMS therapy in early July 2017 and had already utilized this additional timeframe by 10/5/17. Further, on 8/24/17, the patients Patient Health Questionnaire (PHQ-9) score plateaued after treatment 22 at which time the patient was noted to be feeling better. On 9/18/17, the patients mood was much improved. She was doing better and rated her depression a 1 out of 10. At that time, the patients diagnosis was major depressive disorder, in full remission. Given the lack of adequately powered, controlled studies showing the benefit of longer courses of TMS therapy, the request for additional TMS services have not been established as medically necessary for treatment of the patients medical condition. Therefore, 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 Upheld

Summary Reviewer 

A 26-year-old male enrollee has requested reimbursement and prospective authorization and coverage for residential treatment provided from 1/28/18 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 in cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to lack of suicidal ideation. With regards to functional status, the records support a score of 3 due to overall fair functional level at home with some issues with daily activities. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and some history of substance use issues. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable living environment with family members. In terms of level of support of the recovery environment, the records support a score of 2 due to an overall supportive recovery environment and family that is supportive of his treatment. With regards to treatment and recovery history, the records support a score of 3 due to moderate response to past treatment. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment. Thus, the patient has a composite score of 15. This score correlates with low-intensity community-based services. Therefore, the records do not demonstrate the medical necessity of residential treatment. In sum, residential treatment from 1/28/18 and ongoing was not and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 67-year-old male with medical history of gastroesophageal reflux disease (GERD), hyperlipidemia, and hernia repair.  The patient has requested reimbursement for inpatient hospital stay provided from 6/18/21 through 6/20/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the inpatient level of care is not supported based on the submitted documentation. The patient had abdominal pain, nausea, and vomiting, as well as imaging concerning for at least partial small bowel obstruction. However, CT scan of the abdomen and pelvis did not show pathology such as gastrointestinal perforation, abscess, or toxic megacolon. He had gradual advancement of diet, and was tolerating a full liquid diet by 6/20/21. Although uncomplicated small bowel obstruction may have been present, the patient did not have clinical gastrointestinal bleeding, peritonitis, sepsis, or other complications warranting inpatient level of care. The standard of care for uncomplicated small bowel obstruction was performed, including intravenous fluids and gradual advancement of diet, and all could have been performed without the inpatient level of care, at the observation level of care. The measures that were undertaken, including observation, monitoring, laboratory testing, imaging, and advancement of diet, could have been performed without the inpatient level of care. For these reasons, inpatient hospital stay provided from 6/18/21 through 6/20/21 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 41-year-old male has requested authorization and coverage for the LINX procedure.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the patient has eosinophilic esophagitis. It appears that he is having symptomatic improvement with proton pump inhibitor therapy, consistent with the condition of proton pump inhibitor responsive esophageal eosinophilia.  His heartburn and regurgitation respond to proton pump inhibitor therapy as well. There is a lack of literature supporting anti-reflux surgery as a treatment for eosinophilia of the esophagus. The mainstay of treatment includes proton pump inhibitor therapy, topical steroid therapy and diet modification with periodic dilation for refractory dysphagia.  The LINX device could exacerbate dysphagia and make clinical management complex.  In sum, the requested LINX procedure is not likely to be superior over other 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 41-year-old male has requested authorization and coverage for the LINX procedure.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the current medical evidence has not demonstrated the superior efficacy of the requested services in this patients case.  The medical records document gastroesophageal reflux disease as based on pH recording. However, it appears he has benefited to a significant degree from acid suppression treatment, and as such cannot be considered medically refractory to acid blocker drugs. Also, implantation of LINX in this clinical setting must be approached with caution given his documented complaints of dysphagia and probable eosinophilic esophagitis.  In sum, the requested LINX procedure is not likely to be more efficacious than other 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.