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

Summary Reviewer 

A 49-year-old male enrollee has requested reimbursement for residential mental health treatment provided from 8/29/18 through 8/31/18. 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 that 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 2 due to a lack of current 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, but no significant functional problems. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and no active 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 perceived treatment response in the past with residential treatments. Of note, the patients symptom presentation does not indicate a lack of response from recent treatment. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and apparent insight into the need for treatment. Thus, the patient has a composite score of 16. This score correlates with intensive outpatient treatment. Thus, residential mental health treatment provided from 8/29/18 through 8/31/18 were not medically necessary 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 patient is a 46-year-old female who has been diagnosed with both psoriatic arthritis and granuloma annulare. She has tried nonsteroidal anti-inflammatory drugs (NSAIDs), without any relief. The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. Humira has been approved by the U.S. Food and Drug Administration for the treatment of psoriatic arthritis for reducing signs and symptoms, inhibiting the progression of structural damage, and improving physical function in adult patients with active disease. The approval was based on results of clinical trials that showed marked improvement in skin condition. 
Granuloma annulare (GA) is a non-infectious chronic granulomatous dermatosis characterized by annular papules. The response to various treatments, such as topical and intralesional corticosteroids, topical tacrolimus, dapsone, isotretinoin, etretinate or hydroxychloroquine, is usually unsatisfactory. Recently, tumor necrosis factor (TNF)-a inhibitors have been reported to improve GA. Adalimumab (Humira) is an agent that binds to membrane-bound and soluble TNF-a, showing great promise in treating recalcitrant GA. Min and Lebwohl sought to evaluate adalimumabs efficacy in treating GA. They identified seven patients with physician-verified GA who were treated with adalimumab. All patients GA Investigator Global Assessment scores improved by 2 or greater. The authors found significant improvements in body surface area, erythema, and induration (average improvements by 87%, 88%, and 95%, respectively). Adverse events were minimal. Taken together, FDA approval for psoriatic arthritis and published results for GA indicate that adalimumab could be an effective and well-tolerated treatment for both psoriatic arthritis and GA. The patient has already demonstrated efficacy of such treatment. Therefore, Humira is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 64-year-old female enrollee has requested reimbursement for repair of cartilage in the left ankle joint performed on 11/14/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that Osteochondral lesions of the talus occur in up to 70% of acute ankle sprains and fractures. These lesions have become increasingly recognized with the advancements in magnetic resonance imaging (MRI) scans. A fair number of these lesions can remain symptomatic and necessitate surgery. In this case, the lesion had remained symptomatic for over two years before the second surgery. Thus, additional surgery was needed. The type of surgery has included either reparative procedures, such as bone marrow stimulation, or replacement procedures, such as autologous osteochondral transplantation. Reparative procedures are generally indicated for smaller lesions, such as this one. The reparative techniques include debridement and bone marrow stimulation techniques, such as microdrilling and microfracture. Regenerative techniques include autologous osteochondral transplants utilized for larger lesions. A review of the current literature indicates drilling, microfracture and insertion of micronized cartilage and bone marrow aspirate concentrate appears to be a safe and effective treatment option for osteochondral lesions of the talus. The addition of bone marrow aspirate concentrate and micronized cartilage does not result in an increase in ankle or donor site morbidity. It is a well-tolerated therapy that significantly promotes healing and decreases revision rates for treatment of the osteochondral lesions when compared to debridement and microfracture alone. Therefore, repair of cartilage in the left ankle joint performed on 11/14/18 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 




A 52-year-old female enrollee has requested authorization and coverage for endovenous ablation.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees varicose veins. The physician reviewer found there is sufficient support for the requested services in this clinical setting.  Per the submitted documentation, the patient has symptoms which are impacting her activities of daily living.  In a letter dated 4/12/16, the provider noted bilateral leg pain, swelling, numbness, throbbing, and aching when standing.  The current medical evidence supports the requested services for the treatment of this patient.  All told, the requested endovenous ablation is medically indicated in this patients case.  Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 63-year-old female enrollee has requested reimbursement for an Anser ADA test performed on 5/12/15. The Health Insurer has denied this request indicating that the procedure at issue was considered investigational for evaluation of the enrollees Crohns disease with ileostomy. The physician reviewer found that monitoring patients on adalimumab with measurement of adalimumab levels and antibodies to adalimumab continues to be an area of intense investigation. In general, adalimumab levels correlate inversely with disease activity. Unfortunately, the target level of adalimumab necessary to achieve clinical benefit remains unknown. There is limited controlled data which have identified the optimal drug level and the issue remains speculative. More important than the drug level, is the effectiveness and response of the patient to the medication. In an attempt to answer this question in a patient failing therapy, one can set up a hypothetical table categorizing drug levels as high or low and antibody levels as high or low using the Anser ADA. Although appealing, this algorithmic approach has not been validated using prospectively controlled data. The control arm would be to increase the dose of the medication and make a switch when there is sufficient evidence of no response. In short, further studies need to be conducted before the efficacy of the testing can be confirmed.  In this case, the Anser ADA test was not likely to be more efficacious than standard therapy in the evaluation of the patients medical condition. Based upon the information set forth above, the procedure 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 2

A 63-year-old female enrollee has requested reimbursement for an Anser ADA test performed on 5/12/15. The Health Insurer has denied this request indicating that the procedure at issue was considered investigational for evaluation of the enrollees Crohns disease with ileostomy. The physician reviewer found that the use of Anser ADA has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. The effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with adalimumab may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear. The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature (Karmiris, et al; Imaeda, et al; Lichtenstein, et al). These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. The Karmiris study found no direct relationship between trough serum adalimumab concentration or anti-adalimumab antibody and short-term treatment efficacy (Karmiris, et al). Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. Clinical guidelines for management of inflammatory bowel disease do not recommend testing for anti-drug antibody during clinical management (Lichtenstein, et al). A review article reported that the available data do not allow final conclusions about the relevance of anti-adalimumab antibodies to the clinical efficacy of adalimumab, and another concluded that prospective controlled trials are direly needed to investigate the optimal tailored management in individual patients who lose response (Assche, et al; Yanai, et al). All told, the Anser ADA performed on 5/12/15 was investigational for the purpose of evaluating this patients medical condition.
For the reasons set forth above, the procedure 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 63-year-old female enrollee has requested reimbursement for an Anser ADA test performed on 5/12/15. The Health Insurer has denied this request indicating that the procedure at issue was considered investigational for evaluation of the enrollees Crohns disease with ileostomy. The physician reviewer found that for this clinical setting, the Anser ADA test was likely to be more beneficial than any available standard therapy in management and treatment of the patients medical condition. The patient had been on Humira after she had failed multiple prior regimens. There could have been multiple reasons for this, each of which has a different path of management. The Anser ADA test measures the Humira blood level and detects antibodies to Humira.  Patients with detectable levels and no antibodies will have to have a change in treatment management in order to control their disease, as the test implies an escape phenomenon to Humira. Patients with undetectable levels and antibodies are under-dosed and a higher dose will be needed to achieve remission and control of disease.  Patients with a low level and detectable antibodies have a low drug level due to the development of antibodies. Hence, due to the multitude of management options, once a patient loses response to the biologic or has unexplained episodic symptoms that could be attributed to disease flares (such as this patient), the Anser ADA test is an effective tool for the treating provider in the management of their patients medical condition. For these reasons, the Anser ADA test performed on 5/12/15 was like to be more beneficial for evaluation of this patients medical condition than any available standard modality. In sum, the procedure 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 Upheld

Summary Reviewer 1

A 21-year-old female enrollee has requested authorization and coverage for Octagam infusions. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the treatment of autonomic neuropathy can often involve multidisciplinary strategies, both from cardiovascular medicine as well as neurology. This patient has been treated with a variety of modalities, including beta-blocker therapy, fludrocortisone and pyridostigmine, but has some persistent symptomatology. There is the additional factor that there may be comorbidities to suggest autoimmune disorder as well. However, the use of intravenous immunoglobulin to treat autonomic dysfunction remains investigational. The study by Schofield is retrospective and only included 38 patients. There is a lack of support for the requested medication in this clinical setting. Therefore, Octagam infusions are not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 21-year-old female enrollee has requested authorization and coverage for Octagam infusions. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that Dysautonomia is an umbrella term referring to any disorder associated with dysfunction of the autonomic nervous system. There are many different mechanisms by which dysautonomia may arise, but there has been increasing evidence and awareness that it may be immune-mediated in some patients. Autoimmune autonomic dysfunction may be peripheral due to an immune-mediated small fiber polyneuropathy (SFPN) and may manifest clinically as postural tachycardia syndrome, orthostatic intolerance, orthostatic hypotension, inappropriate sinus tachycardia, gastrointestinal dysmotility, complex regional pain syndrome, and/or neurogenic bladder. Intravenous immunoglobulin (IVIG) is a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. Oaklander and Klein reported on the efficacy of immune modulatory therapy in children with SFPN. Fifteen patients were given a trial of immune modulatory therapy with IVIG and/or steroids, and 12 patients (80%) demonstrated improvement. A retrospective analysis by Schofield and Chemali studied the efficacy and safety of IVIG in patients with disabling, refractory autoimmune dysautonomias, including patients with postural tachycardia syndrome and gastrointestinal dysmotility. There were 38 patients, and 83.5% improved on IVIG as defined by at least 20% improvement in the composite autonomic symptom scale 31 and/or functional ability score. The authors concluded, aThere is increasing evidence that IVIG is safe and effective in a subset of patients with autonomic disorders and evidence for autoimmunity. A four-month IVIG trial should be considered in severely affected patients who are refractory to lifestyle and pharmacological therapies.a In this case, the patient has an underlying autonomic nervous system dysfunction on multiple medications. Based on the studies noted above, patients with dysautonomia may improve clinically with intravenous immunoglobulin treatment. Therefore, Octagam infusions are likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 21-year-old female enrollee has requested authorization and coverage for Octagam infusions. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the autonomic nervous system regulates certain body processes, such as blood pressure and the rate of breathing. This system works automatically (autonomously), without a personas conscious effort. Disorders of the autonomic nervous system can affect any body part or process. Autonomic disorders may be reversible or progressive. Intravenous immunoglobulin is an immunological treatment. The patient in question carries several diagnoses, including autonomic nervous system dysfunction. Per the records, this patient has a suspicion of Spiky-Leaky syndrome. Xie and colleagues stated that IVIG may be considered with a clear-cut diagnosis. However, the diagnosis is just suspected in this patient.  The study by Weinstock and colleagues would not apply to this patient, as there is a lack of evidence submitted for this review to support a diagnosis of postural orthostatic tachycardia syndrome or the concurrent use of naltrexone in this case. There is a lack of evidence supporting IVIG as more efficacious than other available standard therapy in this clinical setting. Therefore, Octagam infusions are not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 60-year-old male enrollee has requested reimbursement for St. Jude Nanostim Leadless Pacemaker implant provided on 6/24/15. The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found the services at issue were not likely to be more effective for this patient than other available options. Leadless pacemakers are currently considered controversial and there is a lack of documented contraindications to placement of a traditional endocardial lead. Studies in the peer-reviewed literature suggest that long term complications remain to be determined (Reddy, et al; Miller, et al). All told, the St. Jude Nanostim Leadless Pacemaker implant provided on 6/24/15 has not been established as 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 services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


A 60-year-old male enrollee has requested reimbursement for St. Jude Nanostim Leadless Pacemaker implant provided on 6/24/15. The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found in this case, implantation of a permanent pacemaker was indicated given the patients history of syncope as well as documentation of a four second period of asystole. The implanting provider opined that given the patients active lifestyle he would be better served by a device that did not involve the implantation of transvenous leads. However, the St. Jude Nanostim Leadless Pacemaker is not U.S. Food and Drug Administration (FDA) approved. In addition, the current literature does not support a definitive long term benefit to health outcomes with the St. Jude Nanostim Leadless Pacemaker, and the long term safety and efficacy have not as yet been proven. All told, the St. Jude Nanostim Leadless Pacemaker implant provided on 6/24/15 was not 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 services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 60-year-old male enrollee has requested reimbursement for St. Jude Nanostim Leadless Pacemaker implant provided on 6/24/15. The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition.The physician reviewer found The services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Despite the potential advantages of a leadless device, the long-term data demonstrating safety in large clinical follow-up is lacking. There have also been documented complications of the leadless device. In sum, there is a lack of data supporting the long-term safety and efficacy of the services at issue to establish the St. Jude Nanostim Leadless Pacemaker implant as 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 services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.