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

Summary Reviewer 


The parent of a 17-year-old female enrollee has requested authorization and coverage for mammoplasty, augmentation; with prosthetic implant (19325) and breast reconstruction with other technique (19366). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees breast hypoplasia. The physician reviewer found that based on the medical documentation provided for this review, this patient has a significant congenital breast deformity associated with asymmetric breast hypoplasia. This is supported by the medical documentation from the patients plastic surgeon, endocrinologist and review of the photographs. She has undergone a work-up for correctable causes and no cause, other than a congenital condition, has been found. Her appearance would not be considered relatively normal appearing breasts for a female. The breasts are severely asymmetric and hypoplastic. Therefore, attempts to approximate a more normal appearance should be considered reconstructive and not cosmetic surgery. This is consistent with medically necessary, reconstructive surgery (Sadove and van Aalst; Seyfer, et al). Further, the requested procedure is consistent with the recommendations from the American Society of Plastic Surgeons (ASPS). The ASPS notes that breast reconstruction surgery to correct breast deformities, as well as surgery on the contralateral breast to achieve symmetry, are considered reconstructive surgery and, therefore, should be a covered benefit and reimbursed by third-party payers. Therefore, breast augmentation for this patient should be considered congenital breast reconstruction and is therefore medically necessary. Given these findings, requested authorization and coverage for mammoplasty, augmentation; with prosthetic implant (19325) and breast reconstruction with other technique (19366) are supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, 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 15-year-old female enrollee has requested reimbursement for psychiatric residential treatment center (RTC) services from 5/13/15 through 12/31/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found upon review of the documentation provided, records from 5/13/15 through 12/31/15 show no evidence that the patients behaviors were out of control, or that the patient was psychotic or a danger to herself or others.  Moreover, the records do not indicate that the patient required any special medical or nursing treatment that could not have been provided in a setting other than 24-hour level of care. The notes indicate normal therapy sessions that could have taken place if the patient were an outpatient rather than in a residential setting. The patient was generally cooperative and participated in therapy. She was not aggressive, combative, or incoherent. There is no documentation of particular treatment techniques that would have required an inpatient treatment setting. The patients psychiatrists notes consistently show that the patient was making good progress and that both Seroquel and lithium were no longer needed and were discontinued. Based upon the information stated above, 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 a five-year-old female enrollee has requested authorization and coverage for Tobii Dynavox T10 device and accessories. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollee, who has been diagnosed with cerebral palsy and receptive expressive language disorder. The physician reviewer found that the parent of a five-year-old female enrollee has requested authorization and coverage for Tobii Dynavox T10 device and accessories. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollee, who has been diagnosed with cerebral palsy and receptive expressive language disorder.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 61-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device).  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 there is a lack of support for the requested services in this clinical setting.  The medical records document paroxysmal atrial fibrillation and a prior stroke with no documented significant bleeding complications on anticoagulation.  In this circumstance, atrial fibrillation treatment options include continuation of anticoagulation while accepting an increased bleeding risk, discontinuing anticoagulation while accepting an increased thromboembolic risk or percutaneous left atrial appendage exclusion using a Watchman device.  The Watchman device has been demonstrated in one trial to be non-inferior compared with warfarin.  However, device placement has a high rate of significant complications due to pericardial effusion and procedural stroke related to thromboembolism or air embolization.  The Watchman device is not likely to be of greater benefit than other treatment options, especially in patients who are tolerating anticoagulation without significant bleeding side effects.  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 2


A 61-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device).  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 supports the requested services in this patients case.  The Watchman device is non-inferior to warfarin treatment for long-term stroke prevention due to paroxysmal or persistent atrial fibrillation.  Given this patients recent thromboembolic stroke and known history of paroxysmal fibrillation, as well as higher bleeding risk for systemic anticoagulation, he is an appropriate candidate for the requested services.  Therefore, the requested percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device) is likely to be of greater benefit than other treatment options.  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 61-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device).  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 submitted documentation supports the requested services in this clinical setting.  The left atrial appendage occlusion device (Watchman) has been approved to reduce the risk of thromboembolism from the left atrial appendage in patients with non-valvular atrial fibrillation, who are at increased risk for stroke and are recommended for anticoagulation therapy.  There is sufficient support for the requested services in this patients case.  Many patients with atrial fibrillation take warfarin or other blood thinning medicines to prevent a stroke caused by a blood clot in the brain. However, warfarin can increase the risk of bleeding anywhere in the body.  If bleeding happens in the brain, this can also cause a stroke.  In this patients case, the requested percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device) is likely to be more effective than other treatment options.  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 Upheld

Summary Reviewer 


A 68-year-old female enrollee has requested reimbursement for DecisionDX Melanoma Assay provided on 2/05/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees malignant melanoma. The physician reviewer found that the staging and prognosis of cutaneous malignant melanoma is classically determined by the system spelled out by Balch.  There may be some further value in adding the mitotic rate to this system.  As per this system, this patient would have been staged as a T1a melanoma, with an expected 10-year survival of at least 88%.  There is no information in the records submitted as to whether she had sentinel node done, nor any clinical follow-up since her diagnosis in 2011.  It is also not clear why this assay was ordered in February 2016 when her initial diagnosis was in 2011.  DecisionDX Melanoma Assay is a study of 31 genes in melanoma cells.  It then classifies that particular melanoma as either class 1 (with a 97% disease-free rate at five years) or class 2 (with a 31% disease free-rate at five years).  It is not as yet clear how DecisionDX data compares to the ten-year data of the Balch determinations, and whether it can be used to make clinical practice decisions.  This is particularly in question in this patients case given her pathologic findings and excellent prognosis.  All told, DecisionDX Melanoma Assay provided on 2/05/16 was not medically indicated for the treatment of this patient.  Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

The patient is a 23-year-old female with a history of limited cutaneous systemic sclerosis, Raynauds phenomenon, mild skin tightness, arthritis and gastrointestinal disease. Per the provider, the patient has been treated with sildenafil since 2010 with good results. On 11/20/17, she presented for follow-up. She was to have repeat pulmonary function testing given her worsening shortening of breath and follow-up with subspecialty providers. She continued to have mild depigmentation in her anterior shins, increased dilated blood vessels at the medial ankle, Raynauds at fingers and cold feet. The patients therapies included hydroxychloroquine, methotrexate, pantoprazole, calcium/vitamin D, inhalers and sildenafil. Examination demonstrated mild sclerodactyly, dilated purple ankle vessels at the left ankle, right fourth finger periungual dilation, light tan ill-defined patches on both shins, and multiple blue dilated vessels on left lateral thigh. The plan is to increase sildenafil to, follow-up with gastroenterology, continue Plaquenil, and consider hematology consultation for possible iron infusion. Prior treatment has included nifedipine, Imuran, methotrexate, Rituximab, and Dynacirc without improvement, as well as minocycline. Pulmonary function testing on 12/31/14 showed restrictive chest wall disease, with potential airway disease and an increase in resistance. Echocardiogram on 6/29/16 showed a normal left and right ventricle and systolic function, with no significant change from previous study on 6/26/15. The patient has requested authorization and coverage for sildenafil 20 mg tablets. The Health Insurer has denied this request indicating that the requested medication is not medically necessary. For the treatment of secondary Raynauds phenomenon, the treatment of choice is a calcium channel blocker. Second-line treatment is typically a phosphodiesterase inhibitor (PDE-5). Roustit and colleagues concluded that PDE-5 inhibitors appear to have significant but moderate efficacy in secondary Raynauds phenomenon. Thompson and colleagues reported that PDE-5 medications are able to reduce episodes by 0.5/day which is comparable to calcium channel blockers (CCB) reduction by 0.6/day. In this case, the patient has failed multiple medications to include methotrexate, Imuran, CCB, Dynacirc, and Rituximab. The medical records demonstrate response with sildenafil. All told, the requested sildenafil 20 mg tablets is supported as medically necessary for treatment of this patients medical condition.  Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 23-year-old female enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 2/6/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found that the testing at issue was not likely to be more effective for this patient than other available options. Prometheus Anser IFX Test is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies. Antidrug 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. Some evidence exists that low serum levels of infliximab or adalimumab or the presence of IFX or ADA antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there are few 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. It has not yet 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 sum, there is a lack of sufficient evidence in the peer-reviewed literature to establish the testing at issue as 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 Overturned

Summary Reviewer 2

A 23-year-old female enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 2/6/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found that the testing at issue was likely to be more effective for this patient than other available options. Therapeutic drug monitoring for infliximab and antibodies to the drug is appropriate for optimizing the treatment of the patients who are being treated with Remicade. The loss of response to infliximab can be due to subtherapeutic infliximab levels or the presence of antibodies to infliximab, and performing this assay can be very useful in the management of the patients with ulcerative colitis who are being treated with infliximab. The concept of dose adjustment, based on drug levels, has several potential benefits, one of which is that providers could not only increase drug doses in patients with subtherapeutic drug levels, but could also reduce drug doses in patients with supertherapeutic levels, thereby making the treatment safe for the patients. Therefore, measuring both IFX and ATI concentrations may help guide patient management, optimize care, prevent complications, and reduce long-term morbidity and mortality from complications. Based upon the information set forth above, the testing 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 23-year-old female enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 2/6/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found that the patient has left sided ulcerative colitis disease and has been maintained on Remicade since August 2013. However, she had incomplete response as documented clinically despite being maintained on Remicade. Hence, in the midst of this course, while on adequate therapy, an IFX test was ordered to check for Remicade that would necessitate considering alternate therapy. Thus, the indication for the IFX test was the patients ulcerative colitis and incomplete response being on adequate treatment with Remicade and ruling out alternate causes complicating this course. In this case, the IFX test was indicated due to the multitude of management options once a patient has no response to Remicade and the fact that Remicade has a wide array of adverse effects, it is important for the treating provider to have a roadmap of the nature of the patients clinical course. Therefore, the Prometheus Anser IFX testing performed on 2/6/14 was likely to be more beneficial for evaluation and treatment of the patients ulcerative colitis than any available standard therapy. Based upon the information set forth above, the testing 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


An 18-year-old male enrollee has requested reimbursement and prospective authorization and coverage for applied behavioral analysis (ABA) therapy provided from 9/12/16 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 autism.  The physician reviewer found that ABA therapy is a medically appropriate intervention for the treatment of autism spectrum disorders, and remains one of the most evidence-based interventions available. In this case, the patient has a diagnosis of autism with repetitive, restricted and/or stereotypic behaviors. The patients maladaptive behaviors interfere with his activities of daily living, making it difficult for him to be successful in more generalized environments. ABA therapy has been recommended for treatment of the patients daily living skills in the areas of independent living, job skills, community skills, self-injurious behaviors, aggression and stereotypical behaviors. Moreover, the provider also recommends training for the parents, and other family members and caregivers that are involved in the patients care. The training is to be focused on increasing independent skills while fading direct and indirect prompts required to complete tasks. Based on the clinical documentation submitted for review, ABA therapy provided from 9/12/16 forward was and is medically necessary for treatment of the patients autism. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


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 scienific studies reveal that osteoporosis is an increasingly widespread condition, affecting 55% of Americans aged 50 and above. Of these, approximately 80% are women.  Fractures are the most dangerous aspect of osteoporosis. They can lead to acute and chronic pain as well as increased mortality (Old and Calvert).  A newer medication, denosumab (Prolia) is a fully human monoclonal antibody which has been approved for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone (McClung, et al). Studies support the use of Prolia for the treatment of postmenopausal women with osteoporosis who are at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapies.  This patient met medical necessity criteria for Prolia, as she failed other anti-resportive therapies for her osteoporosis.  Therefore, the medication at issue was likely to be more efficacious in treatment of the patients osteoporosis than any available standard of 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


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 upon review of the medical record, Prolia was likely to be more efficacious in treating the patients medical condition than any available standard therapy. A substantial amount of medical evidence exists to support Prolia as an appropriate treatment option for patients with osteoporosis. Furthermore, Prolia has received Food and Drug Administration approval for the treatment of osteoporosis. The patient has documented osteoporosis with a history of fracture. The DEXA scan of the patients hip and spine demonstrate treatment with Prolia.  In sum, the second injection of Prolia in October 2015 was beneficial for treatment of this patients osteoporosis.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.