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

Summary Reviewer 2


A 49-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of atrial septal defect. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found the requested services are not likely to be more effective for this patient than other available options. Based on an assessment of the peer reviewed literature, the superior benefit of PFO closure versus medical therapy has not been established in cases such as in this clinical setting. The RESPECT trial did demonstrate superiority of PFO closure in patients assigned to the Amplatzer PFO occluder in comparison to guideline directed medical therapy with one or more antiplatelet agents or warfarin (Carroll, et al). However, no significant benefit in the primary intent to treat analysis was documented. In sum, the requested percutaneous transcatheter closure of atrial septal defect is not likely to be more beneficial for treatment of the patients medical condition than any other modalities.Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 49-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of atrial septal defect. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found the request for closure of PFO is not likely to be more effective for this patient than other available options. Studies to date have not shown a clear benefit of transcatheter closure of PFO compared to standard medical therapy. Observational studies from a single institution, non-randomized, suggest some benefit (Inglessis, et al). In sum, there is a lack of sufficient data to support the request for percutaneous transcatheter closure of atrial septal defect for this patient at this patient at this time. Based upon the information set forth above, the services at issue 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 


The parent of a seven-year-old male enrollee has requested reimbursement and prospective authorization and coverage for applied behavioral analysis (ABA) therapy, in excess of 35 hours per week provided from 5/10/16 through 11/8/16. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees autism spectrum disorder.  The physician reviewer found in this clinical setting, ABA therapy in excess of 35 hours per week provided from 5/10/16 through 11/8/16 was and is medically necessary for treatment of the patients medical condition. ABA therapy is medically indicated for children diagnosed with autism. The review by Reichow and colleagues shows that ABA started at a younger age provides improvements in cognitive skills, adaptive skills and language skills. In this case, the patient has received ABA therapy since his diagnosis in 2014. ABA therapy has been effective for him, however he continues to have self-injurious behaviors that include tapping/hitting, elopement and tantrum. Therefore, ABA therapy in excess of 35 hours per week were and are medically necessary for treatment of the patients medical condition. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 26-year-old female enrollee has requested reimbursement for mental health partial hospitalization provided from 1/23/19 through 1/25/19. 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 in 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. With regards to risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. In terms of functional status, the records support a score of 2 due to an overall good functional level with appropriate activities of daily living. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability, no chronic medical issues and no active substance use. In terms of level of stress of the recovery environment, the records support a score of 2 due to no mention of a stressful recovery environment. With regards to level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources. In terms of treatment and recovery history, the records support a score of 2 due to success in the treatment program with a good level of cooperation and stabilization of symptoms. With regards to engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into her need for treatment. Therefore, the patient has a composite score of 13. This score correlates with low intensity community-based services. In sum, this patients presentation did not meet criteria for partial hospitalization program level of care during the disputed timeframe. Thus, mental health partial hospitalization services provided from 1/23/19 through 1/25/19 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

An 18-year-old female enrollee has requested reimbursement for residential psychiatric treatment from 11/16/15 through 7/30/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting. On initial evaluation, the patient was noted to have mood lability, anhedonia, passive suicidal ideation, impulsive behaviors, and poor relationships with peers and family.  During admission to the residential facility, the patient was documented as being grandiose at times, irritable, suspicious of others, anhedonic, and guarded. She was not consistent with completing her activities of daily living and struggled with school assignments. She had difficulty with interacting with peers and would display oppositional behavior towards staff. She also had some difficulties tolerating medications. Aripiprazole was documented as causing confusion and spaciness.  This medication was discontinued on 2/17/16 but subsequent progress notes indicated that the patient continued to struggle with her mood.  From 5/19/16 through 5/22/16, the patient was documented as having a manic episode triggered by medication changes. During this manic episode, the patient also reported hallucinations and delusions and staff had difficulty managing her behavior. She was started on quetiapine and benztropine. She complained of blurry vision and her dose of quetiapine was lowered. On 7/18/16, the patient was documented as having continued irritability and dose of quetiapine was increased.  The record noted that the patients medications were adjusted up until the time of discharge. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth (AACAP). The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity.  These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services. Based on the patients clinical history and documentation as outlined above, the patient met CASII criteria for 24 hour psychiatric monitoring during the disputed dates. The patients clinical status, in addition to current medical literature, support the treatment she received at the residential level of care. Accordingly, residential psychiatric treatment from 11/16/15 through 7/30/16 were medically necessary for the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 30-year-old male enrollee has requested reimbursement for assistant-at-surgery services for surgery (64999-AS) performed on 1/09/19. 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 most surgical procedures, especially major procedures, require an assistant. There were three descriptive codes listed in the operative report, and only the bronchoscopy could be completed solely by the primary surgeon. The robotic-assisted rib resection and neurolysis required coordinated teamwork to facilitate a safe and adequately exposed surgical field. When the surgeon is at the console, the assistant controls instrument placement and suction retraction. Similarly, when part of the procedure is open, the assistant retracts and provides access to prevent injury to adjacent structures.  When re-docked and the neurolysis is completed by freeing the strictured vein, the assistant provides counter-tension, once again protecting other vascular structures and brachial plexus from injury. This patient underwent a major thoracic procedure with a high incidence of neurovascular complications. The current medical evidence supports the services at issue in this clinical setting. Therefore, assistant-at-surgery services for surgery (64999-AS) performed on 1/09/19 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 60-year-old female enrollee has requested reimbursement for collagen crosslinks laboratory tests performed on 1/2/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees osteoporosis. The physician reviewer found that osteoporosis is a condition of thinning of the bones which leads to increased risk of fracture. It is defined by the World Health Organization (WHO) as a bone mineral density of 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults) as measured by dual-energy x-ray absorptiometry.  Bone mineral density (BMD) assessment, via a bone density test, is still the criterion standard for evaluation and diagnosis of osteoporosis.  However, because changes in bone mass and density in response to anti-resorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover (proteins and peptides, referred to as biochemical bone markers, that are released as a consequence of the physiological action of osteoblasts and osteoclasts) may be a useful adjunct in monitoring of osteoporotic patients treated with antiresorptive agents. Evidence suggests that biochemical markers could be useful in making therapeutic decisions because, in general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine. These tests may also assist in identifying individuals with elevated bone resorption, who have osteoporosis in whom response to treatment is being monitored.  Based upon the information set forth above, the services at issue were 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

A 60-year-old female enrollee has requested reimbursement for collagen crosslinks laboratory tests performed on 1/2/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees osteoporosis. The physician reviewer found that biochemical markers of bone remodeling or serum or urinary collagen crosslinks tests are useful in certain situations to monitor efficacy and compliance with therapies for osteoporosis. However, this is not yet standard of care in the medical community, though they have a role in certain clinical situations. In this patients case, the submitted records do not indicate that these tests at issue were superior to available standard therapies for evaluation and treatment of the patients osteoporosis. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 60-year-old female enrollee has requested reimbursement for collagen crosslinks laboratory tests performed on 1/2/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees osteoporosis. The physician reviewer found that according to the Clinicians Guide to Prevention and Treatment of Osteoporosis, biochemical markers of bone turnover may predict risk of fracture independently of bone density in untreated patients, predict rapidity of bone loss in untreated patients, and help determine adequacy of patient compliance and persistence with osteoporosis therapy. These statements are also supported by Burch and colleagues who performed a review regarding the use of bone turnover markers for monitoring the response to osteoporosis treatment. In this case, identifying baseline and subsequently monitoring markers of bone turnover to assist with best therapy options for the patient is medically appropriate and in line with sound medical practice. The requesting provider indicated that these tests were ordered to monitor compliance and response to anti-resorptive therapy. All told, these tests were likely to be more efficacious to guide the therapy for this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 35-year-old female who is pregnant. The patient has requested authorization and coverage for Makena injection (hydroxyprogesterone caproate 10 mg). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that the literature supports the use of progesterone treatment to decrease the risk of preterm delivery in a patient who has a history of preterm birth. Research has shown that a prior spontaneous preterm birth is a risk factor for a subsequent spontaneous preterm birth, whether the initial preterm delivery was a singleton or a twin pregnancy. Although no study has specifically evaluated whether progesterone supplementation decreases the risk of a preterm birth of a singleton after a previous spontaneous preterm birth of twins, it is appropriate for providers to recommend this therapy. There is a theoretical benefit given available data. This provider is practicing within current standard of care, and progesterone therapy is appropriate in this clinical setting. Therefore, Makena injection (hydroxyprogesterone caproate 10 mg) is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 60-year-old male enrollee has requested authorization and coverage for 18F-NaF positron emission tomography/computed tomography (PET/CT) scan. The Health Insurer has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that based upon the recommendations of the National Oncologic PET Registry, the Centers for Medicare and Medicaid Services (CMS) revised its guidelines concerning coverage for PET scans in patients with solid tumors allowing up to three scans in each patient for diagnosis, staging and surveillance. While the use of this compound has proven to be of use in prostate cancer, the re-approval of 18F-NaF as a pharmaceutical has proven of greater benefit to patients with rising PSA levels where bone metastases are possible. The reason is the proven marked increased sensitivity of the technique compared to standard technetium bone scans in the detection and localization of skeletal metastatic deposits. In this patient with a rising PSA after radical prostatectomy, the possibility of subtle skeletal metastatic disease is possible and the requested 18F-NaF PET/CT scan is the most sensitive means with which to evaluate this patient.  Based upon the information set forth above, I have determined the requested diagnostic procedure is 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

A 60-year-old male enrollee has requested authorization and coverage for 18F-NaF positron emission tomography/computed tomography (PET/CT) scan. The Health Insurer has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that in the medical literature, Jadvar and colleagues reported that in patients with relapsed prostate cancer, 18F-NaF PET/CT is useful in the detection of occult osseous metastases, whereas the yield of 18F-FDG PET/CT is relatively limited. Poulsen and colleagues found that 18F-NaF PET/CT were superior to whole body scintigraphy with regard to detection of prostate cancer bone metastases within the spine. Thus, the literature does support 18F-NaF PET/CT to be superior to bone scan with regards to detection of prostate cancer bone metastases within the spine. Further, the requested 18F-NaF PET/CT is the most reliable tool when there is high index of suspicion for osseous metastases. Consistent with this support, the requested 18F-NaF PET/CT scan is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 60-year-old male enrollee has requested authorization and coverage for 18F-NaF positron emission tomography/computed tomography (PET/CT) scan. The Health Insurer has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that the patient does not meet the current guidelines for the requested 18F-NaF PET/CT scan at this time. The National Comprehensive Cancer Network (NCCN) guidelines indicate that although sodium fluoride PET/CT may indeed be a promising technique in the re-staging of prostate cancer, the peer-reviewed medical literature and standards of care do not support the routine use of this study in this clinical setting. All told, the requested 18F-NaF PET/CT scan is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the requested diagnostic procedure is 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 



A 55-year-old male enrollee has requested reimbursement for durable medical equipment (special stockings, Sock Aid Nova and stocking donners) provided on 8/2/16. The Health Insurer has denied this request indicating that the equipment at issue was not medically necessary for treatment of the enrollees lymphedema of both lower extremities. The physician reviewer found that the durable medical equipment (special stockings, Sock Aid Nova and stocking donners) provided on 8/2/16 has been established as medically necessary for treatment of the patients medical condition. The patient presents with limb threatening lymphedema and venous stasis hypertension. This condition has caused ulcerations and cellulitis in the past. Prescription strength compression socks are the standard of care for patients with severely swollen lower extremities including, venous stasis hypertension, and lymphedema. These devices allow for mechanical compression of the lower extremity, facilitating movement of the fluid from the lower extremity proximal for distribution and resorption. This will in turn reduce the patients chance of ulceration, possible cellulitis, and possible further other complications. The compression socks along with the device to pull on the compression socks are medically necessary. The stocking donner is important as socks are difficult for people to place on themselves. It is an important part of the compliance of utilizing compression socks. Thus, the equipment at issue was medically necessary for the patients medical condition.  Therefore, the equipment at issue was 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 59-year-old female enrollee has requested authorization and coverage for an insulin pump. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees diabetes. The physician reviewer found that insulin pump therapy is a technological advancement that has been developed to help patients manage type 1 diabetes. Insulin pump therapy is associated with psychosocial benefits and improved biomedical outcomes (Reidy, et al). Advantages of insulin pump therapy over multiple daily injections of insulin include better adherence, more accurate dosing, greater lifestyle flexibility, control of the dawn phenomenon without induction of nocturnal hypoglycemia, and the ability to suspend or temporarily reduce basal insulin to compensate for increased physical activity (Millstein, et al). While this patient has been able to manage her diabetes via insulin pump therapy, her current pump is no longer functioning. The patient requires a replacement pump in order to optimize her glycemic control. Accordingly, the requested insulin pump is medically necessary for treatment of this patients type 1 diabetes. Based on the foregoing discussion, the requested device is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.