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

Summary Reviewer 

The patient is an eight-year-old female who has been diagnosed with autism spectrum disorder.  The patients parent has requested reimbursement and prospective authorization and coverage for applied behavior analysis provided from 2/01/20 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of this patient. The physician reviewer found that the Council of Autism Service Providers (CASP) autism treatment guidelines include critical features of a treatment plan for service authorization. These guidelines include, but are not limited to, patient information, assessment information, treatment plan, caregiver training, transition and discharge plan, and hours requested. Per the records, these elements were present in this patients case. The goals identified were related to the patients diagnosis of autism (i.e., socialization, communication, stereotypy, self-monitoring, etc.). The authorization request also included baseline data on goals and several graphs detailing progress. Additionally, the requested services meet the medical necessity criteria outlined by Papatola and Lustig. Their definition includes health-care services that a provider, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are: (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. The requested services meet the criteria outlined above. Specifically, the provider has identified how the services will meet the patients essential health needs. Applied behavior analysis is the most evidence-based treatment for autism, and the intensity of services requested is appropriate in this clinical setting. Therefore, applied behavior analysis provided from 2/01/20 forward was and is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The parent of a 17-year-old female enrollee has requested reimbursement for residential mental health treatment for children and adolescents provided from 10/24/18 through discharge. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2. The medical records indicate that the patient was not actively suicidal. The progress notes indicate that the patient was not engaging in self-harm behaviors or expressing suicidal ideation. She did have a history of suicidal ideation. With regards to functional status, the records support a score of 2. The patient had some issues with level of function, but the progress notes indicate significant improvement after a period of deterioration as evidenced by appropriate activities of daily living and grooming as well as therapy participation. In terms of comorbidity, the records support a score of 2. The patient did not have active medical problems, and she reported a history substance use with several substances. She did not describe continued cravings, and there was no documentation of withdrawal symptoms. With regards to level of stress of the recovery environment, the records support a score of 2. The patient was noted to have interpersonal conflict with the family as a focus of treatment. However, the progress notes document that her family therapy sessions were productive and not adversarial. In terms of level of support of the recovery environment, the records support a score of 2. The patients mother was involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 3. The patient had a good response to a short period in the residential treatment center prior to the disputed dates. Her presentation during the disputed timeframe indicates that she was cooperative in treatment. In terms of acceptance and engagement of the patient, the records support a score of 2. The patient actively participated in therapy, and she was able to develop a positive relationship with clinicians. With regards to acceptance and engagement of the parent, the records support a score of 2. The patients parent worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 17. This score correlates with intensive outpatient services. Therefore, residential mental health treatment for children and adolescents provided from 10/24/18 through 11/02/18 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The parent of a 12-year-old male enrollee has requested authorization and coverage for real-time intra-fraction target tracking for planned proton beam radiotherapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees craniopharyngioma status post resection.  The physician reviewer found that this patient presents with craniopharyngioma and is planned for radiation treatment. As the disease is close to optic pathway, any excessive dose to optic pathway will likely cause serious late complications. Thus, the treating provider is using real-time intra-fraction tracking as an extra precaution. This technology has been used in treatment of other tumors to make the treatment precise. Given these findings, the requested real-time intra-fraction target tracking for planned proton beam radiotherapy 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, I have determined the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

The parent of a 12-year-old male enrollee has requested authorization and coverage for real-time intra-fraction target tracking for planned proton beam radiotherapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees craniopharyngioma status post resection.  The physician reviewer found that Overall penumbra volume should be reduced by 50-70% as a result of tracking and therefore may provide reduction in hypothalamic and brain doses. In light of the patients cerebrovascular accident, any further damage to normal central nervous system tissues is likely to be detrimental. The 2 mm or better fixation offered by a thermoplastic mask is adequate to support that the real-time intra-fractional target tracking is likely to be more beneficial than standard alternatives since the tumor is already in contact with the optic pathway. Based upon the information set forth above, I have determined 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


The parent of a 12-year-old male enrollee has requested authorization and coverage for real-time intra-fraction target tracking for planned proton beam radiotherapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees craniopharyngioma status post resection.  The physician reviewer found that based on the medical records, the tumor was in intimate contact with the optic apparatus. The organ surface is at risk for harboring microscopic disease. The optic apparatus needs to be radiated in order to maximize the effectiveness of radiation therapy in disease control. However, avoiding the optic apparatus is not needed and the requested real-time intra-fraction target tracking for planned proton beam radiotherapy 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, I have determined 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 54-year-old male enrollee has requested authorization and coverage for Harvoni.  The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this clinical setting.  According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related comorbid conditions.  It is advantageous to treat patients before they progress to F3 or F4 fibrosis.  Based on published evidence of safety and efficacy in the medical literature, Harvoni is medically indicated 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 20-year-old male enrollee has requested reimbursement for wilderness program services provided from 7/12/18 through 10/08/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that with regard to acute intoxication or withdrawal potential, there were no known signs of symptoms of withdrawal upon admission. However, the risk of protracted withdrawal symptoms, such as heightened anxiety, depression, leading to suicidal ideation warranted close monitoring and structure. In terms of biomedical conditions, the records noted a history of traumatic brain injury. As noted above, there are concerns regarding co-occurring traumatic brain injury and substance use disorder and the increased morbidity and mortality of continued substance use in patients with a known traumatic brain injury. With regard to emotional, behavioral, cognitive conditions, his mental status was sufficient to permit participation. Despite limitations placed on the patient by his parents, his behavior continued to escalate to the point that he was at high risk of harm to self or others if his substance use and related behaviors were not curtailed. He had failed lower levels of treatment to include psychiatric outpatient treatment (medication management and therapy) following his inpatient admission in June 2018. In terms of readiness to change, the patient initially had limited insight for need for treatment but relented due to his parents continued requests and his deteriorating condition prior to admission. He had demonstrated a known resistance to being controlled. His perspectives impaired his ability to make care decisions, as evidenced by his impulsive behaviors. With regard to relapse, continued use, or continued problem potential, the patient had risk-taking behavior that was escalating to the point of aggression and not responding to parental limits, leading to a prior inpatient psychiatric admission. However, after discharge from the hospital, little change occurred. His maladaptive behaviors, such as need for immediate gratification, poor judgment, limited coping skills and low frustration tolerance, placed him at imminent danger of relapse if not in a structured setting that provided tools for improved coping and living a sober lifestyle. In terms of recovery environment, the home setting (with his parents) was not conducive to continued recovery. Therefore, wilderness program services provided from 7/12/18 through 10/08/18 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 50-year-old female enrollee has requested authorization and coverage for minimally invasive sacroiliac joint fusion. 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 patient has chronic left sacroiliac dysfunction and pain that interferes with activities of daily living. The selected procedure of minimally invasive sacroiliac fusion using the triangular titanium implant is a relatively popular procedure, with 88 percent fusion rate and documented excellent results at five-year follow-up. Minimally invasive sacroiliac joint fusion has become an increasingly popular and accepted surgical option for chronic sacroiliac joint dysfunction, a common cause of unremitting chronic low back/buttock pain. Minimally invasive sacroiliac joint surgery has been proven to be a safe and effective procedure, with a high fusion rate, a good safety profile and significant improvements in pain severity and disability reported through 12 months post-procedure. A five-year follow-up showed continued excellent clinical responses in patients with sacroiliac joint pain treated with sacroiliac joint fusion using triangular titanium implants along with a high rate of joint fusion. Therefore, the requested minimally invasive sacroiliac joint fusion is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 50-year-old female enrollee has requested authorization and coverage for minimally invasive sacroiliac joint fusion. 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 submitted documentation fails to demonstrate the superior effectiveness of the requested services. While there is more convincing evidence to support arthrodesis for primary sacroiliac conditions with identified on imaging or with rheumatologic pathology such as trauma, tumor, spondyloarthropathy or infection, the evidence is much less clear when there is confounding degenerative pathology in the lumbar spine. In addition, the criteria for diagnosis of sacroiliac joint mediated pain remains unclear, and pain relief with injection is not recognized universally as the gold standard. In this case, the patient has been diagnosed with left sacroiliac joint dysfunction. She does have some physical examination findings that localize her symptoms to the left sacroiliac joint. However, there are no objective imaging or laboratory findings to indicate the presence of sacroiliac joint infection, tumor, sacroiliitis due to spondyloarthropathy or post-traumatic arthritis. The imaging studies do not demonstrate objective evidence of left-sided sacroiliac joint pathology but do demonstrate confounding multilevel lumbar degenerative changes. There is a lack of support for the requested services in this clinical setting. Therefore, the requested minimally invasive sacroiliac joint fusion is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 50-year-old female enrollee has requested authorization and coverage for minimally invasive sacroiliac joint fusion. 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 International Society for Advancement of Spine Surgery (ISASS) policy statement for minimally invasive sacroiliac joint fusion provides specific indications for surgery. In addition to such specific criteria, it is noted, aAdditional or alternative diagnoses that could be responsible for the patientas ongoing pain or disability have been clearly considered, investigated and ruled out.a In this patientas case, there are potential alternate and/or additional contributing diagnoses. The three clinical reports are significantly varied regarding subjective and objective findings documented.  For example, on 9/18/20, the documented findings suggested multiple alternate pain generators, plausibly inclusive of the thoracolumbosacral regions of the spine itself.  There were multiple denoted subjective and examination findings in the 9/18/20 report that were not significantly discussed and/or completely ruled out as significant plausible pain generators in the subsequent clinical reports. The medical literature at large does not exclusively rely on injection results as being 100% diagnostic of sacroiliac joint(s) as the clear pain generator, in isolation. Nor are the denoted sacroiliac joint injection results dispositive for a definitive surgical indication, again when considered within the realm of the entirety of records reviewed. Furthermore, multiple other plausible pain generators including at the lumbosacral spine are evident. Therefore, the requested minimally invasive sacroiliac joint fusion is not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 65-year-old male who experienced a syncopal episode in June 2021. The patient has requested authorization and coverage for a transcatheter aortic valve replacement. The Health Insurer has denied this request and reported that the requested services are not medically necessary 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. Both the Evolut low risk trial and the PARTNER 3 trial have shown that transcatheter aortic valve replacement is non-inferior and perhaps slightly superior to surgical aortic valve replacement in low surgical risk patients such as this patient. Transcatheter aortic valve replacement has the additional significant advantage over surgical aortic valve replacement in shortening the length of hospital stay. Therefore, the requested transcatheter aortic valve replacement is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 33-year-old male enrollee has requested authorization and coverage for PET imaging with CT attenuation skull base to mid thigh. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that PET/CT has become the most important imaging modality to evaluate lymphoma. PET/CT plays a crucial role in staging, restaging, prognosis, planning treatment regimens, monitoring therapy, and detecting disease recurrence. Generally, clinical symptoms provide the earliest evidence of recurrence, and approximately 80% of patients with proven recurrence are symptomatic. In this case, the patient is currently symptomatic, with multifocal pain as well as generalized symptoms, such as fatigue. The patients disease is particularly aggressive, and he initially presented with an abdominal mass at the time of diagnosis. Therefore, in a patient with abdominal pain particularly, imaging is necessary to exclude disease recurrence. The most accurate imaging modality to assess for recurrence is PET/CT. Thus, PET with CT attenuation, skull base to mid-thigh, is medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 59-year-old male enrollee has requested authorization and coverage for Orthovisc series (J7324 x 4). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees knee pain. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested services. The peer-reviewed literature supports the use of hyaluronic acid injections, such as Orthovisc, for the treatment of knee osteoarthritis and indicates that these injections provide a longer lasting benefit than intra-articular corticosteroid injections. Given that the patients provider has advised against the use of intra-articular corticosteroid injections due to his hypertension, proceeding with corticosteroid injections would not be warranted or consistent with peer-reviewed literature. Therefore, the requested Orthovisc series x 4 is medically necessary for the treatment of the patients medical condition. For the reasons provided, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.