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

Summary Reviewer 3

A 55-year-old male enrollee has requested reimbursement for CPT code 81479 provided on 12/21/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features, such as the grade of tumor and prostate-specific antigen level. This helps guide the most appropriate therapy for patients, taking into account their age and comorbidities, because many patients will not require therapy (i.e. surgery or radiation) and may be followed closely instead. The important features to recognize are Gleason score and prostate-specific antigen level, but these are imperfect. Thus, current biomarkers are inadequate for risk stratification, and better prognostic biomarkers are needed. The Oncotype DX is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score (GPS). The GPS may help identify patients with very low risk disease that can be followed rather than referred for surgery. The medical evidence supports the services at issue in this clinical setting. Thus, CPT code 81479 provided on 12/21/18 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 35-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. According to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for treating hepatitis C, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Moreover, the combination of ledipasvir/sofosbuvir Harvoni is recommended for hepatitis C genotype 4 patients based upon trial studies (Kapoor, et al; Abergel, et al). Abergel and colleagues reported data from an open-label single-arm study including 22 HCV genotype 4 infected, treatment-naive patients (only 1 with cirrhosis) with an SVR rate of 95% (21/22) at 12 weeks. Therefore, the request for Harvoni is medically necessary for treatment of the patients HCV genotype 4 infection. For the reasons provided, 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 Upheld

Summary Reviewer 1

A 67-year-old male enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees bilateral sacroiliac joint pain status post revision lumbar surgery. The physician reviewer found that according to the coverage criteria by the International Society for the Advancement of Spine Surgery (ISASS), the criteria for sacroiliac joint fusion have not been met in this patients case. The patients records do not include documentation of failure to respond to at least six months of non-surgical treatment consisting of non-steroidal anti-inflammatory drugs and/or opioids and one or more of the following: rest; physical therapy; or sacroiliac joint steroid injection must be reported. Moreover, there must be evidence that additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been ruled out. Thus, although the patient has demonstrated continued pain that interferes with activities of daily living and results in functional disability, the patient has not adequately satisfied all of the ISASS criteria. All told, the requested sacroiliac joint fusion is 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 requested service 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

A 67-year-old male enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees bilateral sacroiliac joint pain status post revision lumbar surgery. The physician reviewer found that the medical records indicate that the patient has had previous lumbar fusion surgery. Currently, there is a lack of documentation of sacroiliac joint instability, fracture, or tumor. For this reason, the criteria for sacroiliac joint fusion have not been met. Further, long-term outcomes and complications are not well-defined for use in this clinical setting. Given these findings, the requested sacroiliac joint fusion is not supported 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 requested service 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

A 67-year-old male enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees bilateral sacroiliac joint pain status post revision lumbar surgery. The physician reviewer found that this patient presents with persistent severe left greater than right SI joint pain. Functional difficulty was documented with activities of daily living and ambulation. He is status post multiple lumbar fusion surgeries resulting in L3-4, L4-5 and L5-S1 interbody fusion with posterior instrumentation from L3 to S1. He has reported progressively worsening bilateral SI joint pain following the last surgery on 11/1/16. There is evidence of long-term conservative treatment including medications, cane/walker use, bracing, activity modification, SI joint injections, home exercise program, and physical therapy without sustained improvement. Clinical examination findings have documented SI joint tenderness with three positive SI provocative tests. In addition, there is radiographic evidence of SI joint sacroiliitis. Moreover, bilateral SI joint injections have been documented with 90-100% temporary pain relief. Current evidence based medical guideline and peer-reviewed surgical indications for SI joint fusion have therefore been met. Accordingly, the requested SI joint fusion 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 service is 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 62-year-old female enrollee has requested reimbursement for hospital services provided on 2/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees dislocated thumb. The physician reviewer found the inpatient admission was not medically necessary in this patients case. Inpatient care is necessary when the patients signs, symptoms, and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. The documentation provided did not support acute exacerbations of chronic medical problems. The records indicated that the patients pain was controlled. She could have been treated at a lower level of care for the procedure. Per InterQual criteria for acute inpatient admission, the criteria was not met? in this patients case. As such, the hospital services provided on 2/6/17 were not medically necessary for the treatment of this patients medical condition. Therefore, for the reasons 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


The parent of an 11-year-old male enrollee has requested reimbursement for the Prometheus Anser IFX test performed on 7/16/14. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis.   The physician reviewer found that on the current peer-reviewed medical literature, the Anser IFX test is used as part of standard of therapy in patients who treated with infliximab to determine whether a patient is benefiting from the drug or if they need an increased dose. The information received from this test may lead to a shortened interval or increased dose or possibly change of medication. The Anser IFX test helps to inform the provider whether the serum levels of drug are in the range to be beneficial and effective or if a patient has antibodies that could potentially lead to a reaction, failure to respond. This can help guide the provider in dosing or may lead them to discontinue the drug if the patient is not likely to benefit from the medication. This can not only prevent the patient from having a flare but save them from potential side effects of a drug they may not benefit from. In this case, the patient was on infliximab but started having rectal bleeding. Thus, the Anser IFX testing performed on 7/16/14 was 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 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


The parent of an 11-year-old male enrollee has requested reimbursement for the Prometheus Anser IFX test performed on 7/16/14. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis.   The physician reviewer found current studies indicate that measurement of infliximab levels and anti-infliximab antibodies produces actionable data (Afif, et al; Yanai and Hanauer). Change of dose or medication based on these results improves response to treatment, as measured by clinical response. Minar and colleagues reported that among 60 pediatric Crohns patients with secondary loss of response, a total of 23 patients had subtherapeutic infliximab levels and 11 had antibodies to infliximab. Overall, 29 patients had a change of treatment prompted by the results of drug monitoring. This group had a rate of clinical remission at six months similar to those whose treatment was considered appropriate based on drug monitoring results. Among the subgroup of patients whose treatment change was an intensification of infliximab dosing, remission rate increased from 16% at baseline to 72% at six months. Hoekman and colleagues demonstrated that lower infliximab trough levels is associated with elevated markers of mucosal inflammation in children. Given this support, the Anser IFX testing performed on 7/16/14 was 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 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


The parent of an 11-year-old male enrollee has requested reimbursement for the Prometheus Anser IFX test performed on 7/16/14. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis.   The physician reviewer found that in the current peer-reviewed medical literature, Yanai and Hanauer concluded that although the incorporation of the measurement of trough levels and anti-drug antibodies may be helpful in this clinical setting, prospective controlled trials are direly needed to investigate the optimal tailored management in individual patients who lose response. The testing for trough IFX levels and antibodies are appropriate and within the accepted standard of practice now in patients treated with IFX. The Anser IFX testing in this patients case was non-trough. All told, the mid treatment Anser IFX lab test performed on 7/16/14 was not likely to be more beneficial for evaluation of this patients ulcerative colitis than any available standard testing. 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 

The patient is a 35-year-old male who was admitted on 9/17/18. The records noted acute psychosis due to auditory hallucinations, disorganized behavior, and homicidal threats toward his parents, whom he was living with. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is a beneficial tool in determining the appropriate level of care. With regard to risk of harm, the records support a score of 5 due to homicidal ideation, auditory hallucinations, paranoia and delusions. His ability to decompensate due to noncompliance remained high. In terms of functional status, the records support a score of 5 due to inability to provide for basic needs due to his symptoms. His comorbidity dimension was scored a 2. He had severe mental illness. Due to lack of cooperation with medical staff, other medical conditions were difficult to determine. In terms of level of stress of the recovery environment, the records support a score of 4 due to lack of employment, housing, and inability to manage his day-to-day life. With regard to level of support of the recovery environment, the records support a score of a 3. The records noted involvement of parents and other agencies to help him, but a lack of connection to friends or employers. In terms of treatment history, the records support a score of 4 due to multiple hospitalizations, multiple treatments that failed due to noncompliance due to symptoms of schizophrenia. With regard to engagement, the records support a score of 5 due to refusal to take vital signs, take blood draws, and refusal to participate in group and individual therapy. Therefore, the records support a score of 28. The records support inpatient hospitalization in the patients case. Thus, inpatient behavioral health services provided from 10/01/18 through 11/12/18 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 
The patient is a 46-year-old female who has requested reimbursement for laboratory testing (81219 and 81403) provided on 6/29/20.  The patient has requested reimbursement for laboratory testing (81219 and 81403) provided on 6/29/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the patients medical condition. This denial is the subject of this appeal and determination. The physician reviewer found that myeloproliferative disorders, such as essential thrombocytosis, polycythemia vera, and primary myelofibrosis, are suspected when a patient has persistent leukocytosis and thrombocytosis. Usually, platelets are persistently elevated above 500, white blood cell count is above 30 and some abnormal appearing white blood cells are usually seen. On 6/29/20, this patient had a normal white blood cell count and platelets, and a peripheral smear was described as normal. Based on these findings, a myeloproliferative disorder would be of low suspicion and further confirmatory tests such as JAK2 V617F cascading reflex to CALR, JAK2 exon 12, MPL, and CSF3R would not be indicated. There is a lack of support for the services at issue in this clinical setting. Therefore, laboratory testing (81219 and 81403) provided on 6/29/20 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 60-year-old female enrollee has requested reimbursement for the emergency department services provided at Hoag Hospital on 12/1/16. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. The patients symptoms on 12/1/16 did meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize his or her health. The patient was directed to go to the emergency department by her primary care provider to rule out diverticulitis. She was evaluated and found to have diverticulitis, was offered admission, and declined. She was prescribed oral antibiotics. The medical records support a comprehensive history and medical decision making of high complexity to support CPT code 99285. The patient then left and went to the second emergency department. There she received one dose of intravenous antibiotics and was discharged. All told, the emergency department services provided at Hoag Hospital on 12/1/16 were required on an emergent basis and include comprehensive history and medical decision making of high complexity to support CPT code 99285. Therefore, the Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 52-year-old male enrollee has requested reimbursement for acute hospital admission at telemetry level of care provided from 2/13/18 through 2/14/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who reported chest tightness. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had known coronary disease and presented with atypical (at rest) chest pain without any objective evidence of coronary ischemia or hemodynamic instability.  In this circumstance, it would have been reasonable to anticipate a hospital length of stay less than two midnights, and it would have been safe to manage the patient at an observational level of care as opposed to a hospital admission. After the initial evaluation, it was not likely that the patient had an acute coronary syndrome based on the above findings. Thus, acute hospital admission at telemetry level of care provided from 2/13/18 through 2/14/18 was 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 parent of a 13-year-old male enrollee has requested authorization and coverage for Cimzia loading dose 400 mg (two injections), then 200 mg subcutaneous every two weeks, three applications. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who has been diagnosed with inflammatory bowel disease, psoriasis and juvenile ankylosing spondylitis. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this clinical setting. Cimzia is an anti-tumor necrosis factor medication which is indicated for the treatment of psoriasis, inflammatory bowel disease and ankylosing spondylitis/sacroiliitis. These diseases are the same in children and adults and respond to therapy similarly. Currently, there is an active trial being conducted, the Pediatric Arthritis Study of Certolizumab Pegol (PASCAL). This is a phase 3, multicenter, open-label study to assess the pharmacokinetics, safety, and efficacy of certolizumab pegol (Cimzia) in children and adolescents with moderately to severely active polyarticular-course juvenile idiopathic arthritis. In this patients case, Cimzia is a medically appropriate treatment option. Thus, Cimzia loading dose 400 mg (two injections), then 200 mg subcutaneous every two weeks, three applications are medically necessary for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 55-year-old female enrollee has requested reimbursement for CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy provided from 2/10/15 through 2/13/15. The Health Insurer 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 submitted letters from the patient and provider were reviewed.  However, there is a lack of additional pertinent medical documentations, such as progress notes from the ordering provider.  The progress notes submitted are from a different provider which documented the diagnosis of mast cell disorder, chemical sensitivities and food allergy.  The only records from the ordering provider were testing records, which are insufficient to support the services at issue.  The submitted records do not support a covered indication for the services at issue.  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.