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

Summary Reviewer 1

An 80-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire airway stimulation. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition.The physician reviewer found that this patient has obstructive sleep apnea and has no significant nasal obstruction. The drug-induced sleep endoscopy showed no concentric collapse at velum and primarily anterior posterior collapse at the oropharynx. The patient has not been able to tolerate the continuous positive airway pressure (CPAP) device. The Inspire device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of obstructive sleep apnea. At this point, the patient is a candidate for the Inspire device given the intolerance to CPAP, anterior posterior collapse at the oropharynx, and body mass index and apnea-hypopnea index within FDA criteria. Therefore, hypoglossal nerve stimulation or Inspire airway stimulation is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

An 80-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire airway stimulation. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient has already failed CPAP therapy and is not an optimal candidate for oral appliance therapy due to the severity of his obstructive sleep apnea. Multiple studies have demonstrated that hypoglossal nerve stimulation or Inspire airway stimulation improves health for people with obstructive sleep apnea with clinically significant decreases in observed mean apnea-hypopnea index and improvements in quality of life. The American Academy of Otolaryngology-Head and Neck Surgery considers aupper airway stimulation via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be a safe and effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy.a All told, hypoglossal nerve stimulation or Inspire airway stimulation is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

An 80-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire airway stimulation. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the hypoglossal nerve stimulator is the most appropriate procedure and implant for the patient, considering potential benefits and harms. It is known to be effective based on scientific evidence in improving health outcomes. There are several studies that have looked at hypoglossal nerve stimulation as a way to improve upper airway stimulation and thereby treat obstructive sleep apnea. Strollo and colleagues published a study evaluating a multicenter, prospective, single-group cohort who had the device implanted. The authors concluded that aupper airway stimulation led to significant improvements in objective and subjective measurements of the severity of obstructive sleep apnea.a There is long-term data that shows a reduction in the severity of obstructive sleep, good patient compliance, a reduction in sleepiness, and improvement in quality of life. In this patientas case, he meets FDA criteria for the device. He has tried and failed CPAP treatment. His sleep study does not show evidence of central sleep apnea. In addition, he does not have complete concentric collapse of the upper airway. Finally, his apnea-hypopnea index is within the appropriate range. Thus, hypoglossal nerve stimulation or Inspire airway stimulation is likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 39-year-old female who has a history of migraines and palpitations. The patient has requested reimbursement for laboratory testing performed on 11/12/19 and 1/17/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that this patient had a persistent thrombocytosis with a platelet count greater than 450 on three separate occasions. Iron studies are reported to be normal. It could not be determined from peripheral studies if the thrombocytosis was reactive or part of a myeloproliferative neoplasm or other neoplastic process. Molecular studies on peripheral blood were negative. Performing a bone marrow biopsy in this situation is a standard of care. Given the differential diagnosis, the services at issue are standard. The medical records support the services at issue in this clinical setting. Therefore, laboratory testing performed on 11/12/19 and 1/17/20 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a nine-year-old male. The patients parent has requested reimbursement for speech therapy provided from 1/12/19 through 10/19/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient.   The physician reviewer found that the patient has autism spectrum disorder and attention deficit/hyperactivity disorder, predominantly inattentive subtype. He has significant impairment in the appropriate social use of pragmatic language, which is causing difficulty with social interaction with his peers and adults. His language difficulties are also adversely affecting his school performance. The patient will be at significant risk of anxiety and depression as a result of his language impairment. Maiano and colleagues estimated that 44% of children with autism are bullied at school. This is frequently due to their difficulty interacting appropriately with others. Helland and Helland recommended that the substantial influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism, and that further development of therapy plans and interventions targeting pragmatics is strongly needed. There is sufficient support for the services at issue in this clinical setting. Therefore, speech therapy provided from 1/12/19 through 10/19/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 59-year-old male enrollee has requested authorization and coverage of Harvoni for 12 weeks. 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 according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines do not recommend deferring treatment in patients with illicit alcohol or drug use, and in fact prioritize patients who use intravenous drugs due to benefits in disease transmission reduction.  The patient should be considered treatment-naive because he failed interferon rather than PEG-interferon.  The guidelines recommend that non-cirrhotic treatment-naive patients, or those who failed PEG-interferon/ribavirin, should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For the reasons stated above, the requested medication is 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 13-year-old female enrollee has requested reimbursement for emergency medical services provided on 8/02/18. The Health Insurer has denied this request and reported that the services at issue were not required on an emergent basis. The physician reviewer found that this patient presented after a wick, which had been placed following abscess drainage, fell out. The patients mother was concerned that an abscess was re-developing. In most cases, following an incision and drainage of an uncomplicated skin abscess with a wick left in place, the patient is advised to return for packing removal. The patient presented on a Thursday morning. She had no fever or other sign of systemic infection. Her vital signs were normal. The infection had not suddenly worsened or spread. Although the patient may have warranted medical attention, this care could safely have been provided on a non-emergent basis. A patient who has already undergone abscess incision and drainage with recurrent swelling at the site without fever does not meet prudent layperson criteria for an emergency. A prudent layperson in these circumstances would not reasonably expect the absence of emergency care to jeopardize ones health. Therefore, this patients symptoms on 8/02/18 did not meet prudent layperson criteria for emergency care.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 25-year-old female has requested authorization and coverage for intravenous ceftriaxone. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the superior efficacy of the requested medication in this patients case. This patient has not demonstrated clinical evidence for neuroborreliosis. She has no neurologic findings. There is no abnormal cerebrospinal fluid, imaging or serology consistent with neuroborreliosis. The patient has received a four-week course of ceftriaxone, which is the standard course. Repeated or long-term therapy has not been shown to be efficacious. The treatment of Babesia is not with ceftriaxone, and Brucella is not a pathogen that is treated with ceftriaxone. All told, the requested intravenous ceftriaxone is not likely to be superior over other available treatment options.  Based upon the information set forth above, the requested medication 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 25-year-old female has requested authorization and coverage for intravenous ceftriaxone. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found the medical evidence does not support the requested medication in this clinical setting.  This patient was diagnosed with neuroborreliosis per the submitted records. Current Lyme disease guidelines and data indicated that ceftriaxone is recommended for 14 to 21 days.  This patient has been treated with intravenous ceftriaxone for 28 days.  In addition, doxycycline has been shown to be non-inferior to ceftriaxone in some studies. Moreover, atovaquone and azithromycin are standard treatment regimens for Babesia.  For those reasons, the requested intravenous ceftriaxone is not likely to be of greater benefit than other available treatment alternatives. Based upon the information set forth above, the requested medication 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 25-year-old female has requested authorization and coverage for intravenous ceftriaxone. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the requested medication in patients case. There is a lack of evidence that this patient has Lyme disease. Late stage Lyme disease does occur, but involves the heart, joints or the central nervous system. This patient has had no arthritis or heart block and has a normal neurological examination. There is also no credible laboratory evidence she has Borrelia infection. Treatment with parenteral antibiotics is not supported by the information provided.  Thus, intravenous ceftriaxone is not likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested medication 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 12-year-old male enrollee has requested authorization and coverage for Otezla (Apremilast Tab Starter Therapy Pack 10 MG & 20 MG & 30 MG). 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 Apremilast is a phosphodiesterase-4 inhibitor that has been U.S. Food and Drug Administration (FDA) approved for the treatment of psoriatic arthritis. It targets the inflammatory cascade at an earlier point in time to have a broader pro-inflammatory response target. This medication has a low side effect profile and is well-tolerated by patients. It is particularly useful for patients who have failed other treatments because of side effects or lack of efficacy. It has been successfully used in adolescents, but is not yet FDA approved for that population. The problem with tumor necrosis factor inhibitor medications, such as Enbrel and Humira, is that patients are at significant risk of infection. Those particularly susceptible are individuals with chronic or recurrent infections. This patient has been diagnosed with post-infectious encephalopathy and has a history of recurrent infections that have exacerbated his neuropsychiatric symptoms. In this particular case, use of apremilast is medically necessary and appropriate. Therefore, Otezla (apremilast tablets starter therapy pack 10 mg and 20 mg and 30 mg) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 46-year-old female enrollee has requested authorization and coverage for endovenous ablation therapy of the right SSV. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. The Health Insurers denial was based upon the size of the small saphenous vein that will be the target of treatment. Per the records, the vein has reflux. Although increasing saphenous vein size does correlate with severity of vein disease, patients with C2-C3 disease still have been reported to have small saphenous veins measuring as small as 2.4 mm at the junction (mean of 4.3 mm). In order to determine the medical necessity of the treatment, the total clinical picture must be evaluated. In this patients case, she is likely to benefit from the requested services. Therefore, endovenous ablation therapy of the right small saphenous vein is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 44-year-old male enrollee has requested authorization and coverage for lumbar spinal fusion. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees lower back pain. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the procedure at issue. Resnick and colleagues recommend surgery for spinal stenosis for patients who do not improve with conservative treatment. Numerous studies have demonstrated the role of surgical decompression in this patient population; however, few have investigated the utility of fusion in patients without underlying instability. The inclusion of fusion is recommended for patients with demonstrated spinal instability or the likelihood of iatrogenic instability (Resnick et al). Fusion may be supported for segmental instability (objectively demonstrable) including excessive motion, as in isthmic or degenerative spondylolisthesis, surgically induced segmental instability and mechanical intervertebral collapse of the motion segment and advanced degenerative changes after surgical discectomy. Pre-operative clinical surgical indications require completion of all physical therapy and manual therapy interventions, x-rays demonstrating spinal instability, spine pathology limited to two levels, and psychosocial screening with confounding issues addressed. Ghogawala and colleagues reported that the results of recent studies suggest that a patient's pretreatment psychological state is a major independent variable that affects the ability to detect change in functional outcome. In this patients case, the above-noted evidence-based medical guidelines and peer-reviewed criteria have not been met. This patient presents with persistent and worsening low back pain radiating into both lower extremities. He reported difficulty with functional mobility due to right lower extremity numbness and weakness. There are no clinical findings of nerve root compromise correlated with imaging evidence of degenerative disc disease at L4/5 and L5/S1. Discography is of limited diagnostic value. There is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There is no imaging evidence of significant facet arthropathy supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. There is no evidence of a psychosocial assessment. Therefore, the requested lumbar spinal fusion is not considered medically necessary for the treatment of this patients medical condition. Based on the submitted documentation and per accepted clinical guidelines, the requested procedure is 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 

A 33-year-old female enrollee has requested reimbursement for laboratory services (82746, 82607 and 82306) provided on 6/05/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting. Kennel and colleagues noted, Even when using a conservative definition of vitamin D deficiency, many patients routinely encountered in clinical practice will be deficient in vitamin D. The authors reported, It has been suggested that clinicians should routinely test for hypovitaminosis D in patients with musculoskeletal symptoms, such as bone pain, myalgias, and generalized weakness, because these symptoms are often associated with hypovitaminosis D and might be misdiagnosed as fibromyalgia, chronic fatigue, age-related weakness, or even depression. Green noted, There are numerous known causes of deficiency of folate or vitamin B-12. In some situations, such as chronic generalized malabsorption or malnutrition, deficiencies of both vitamins may coexist. Hunt and colleagues noted that vitamin B12 deficiency occurs at high rates in South Asia. Also, the risk of vitamin B12 deficiency is higher in individuals who consume alcohol heavily. In this case, the patient is of South Asian descent and had recently returned to the United States after living there for an extended period. He reported that he had been self-medicating with alcohol. He reported shoulder pain, anxiety, and low mood, and also reported being treated with weekly vitamin D supplements in the past. For all of the above reasons, it was medically appropriate for the patients provider to check levels of vitamin D, B12, and folate at the initial visit. Therefore, laboratory services (82746, 82607 and 82306) provided on 6/05/19 were medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 58-year-old male enrollee has requested authorization and coverage for Repatha.  The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollee, who has a history of atherosclerotic cardiovascular disease. The physician reviewer found that per the records, this patient has known coronary disease, documented intolerance to moderate and higher dose statin medications and elevated low-density lipoprotein level above goal despite the combination of highest tolerable statin dose and ezetimibe.  In this circumstance, treatment with a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor is reasonable and appropriate based on current evidence.  Repatha is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of low-density lipoprotein levels.  This patient fits the latter criteria.  However, the Health Insurer has offered coverage for Praluent as an alternative. Praluent is also a PCSK9 inhibitor and is a reasonable alternative to Repatha. Thus, although a PCSK9 inhibitor is medically appropriate, the records do not demonstrate the medical necessity of Repatha as opposed to the alternative medication Praluent. In sum, Repatha is not medically necessary for the treatment of this patient. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.