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

Summary Reviewer 1


A 65-year-old female enrollee has requested reimbursement for autonomic nerve function testing performed on 3/26/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  While autonomic testing can be useful in select cases where clear autonomic symptoms and findings have been documented, it should not be used in generic cases where a patient is noted to have pain.  In this case, the records do not clearly demonstrate marked autonomic findings or symptoms.  In the absence of this, autonomic testing has not been shown by clinical studies to statistically improve the management of patients.  The patient can be evaluated for treatable causes of peripheral neuropathies in the absence of the requested testing.  All told, autonomic nerve function testing performed on 3/26/15 was not likely to have been of greater benefit than other alternatives.  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 Upheld

Summary Reviewer 2


A 65-year-old female enrollee has requested reimbursement for autonomic nerve function testing performed on 3/26/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the medical records provided for review do not indicate focal neurologic disturbance in regards to motor, sensory, reflex, coordination, gait or cranial nerve or cognitive function.  The clinical notes do not document by history the presence of any issue of labile blood pressure, orthostatic hypotension, or passing out episodes.  There is no indication of neuropathic pain being reported in terms of having hypersensitivity or allodynia.  Autonomic nervous system testing is useful for evaluation of autonomic nervous system when there are autonomic nervous system related symptoms.  The available medical records provided for review does not support the presence of subjective symptoms consistent with autonomic nervous system abnormality or indicate objective findings on physical examination of autonomic nervous system dysfunction.   Therefore, autonomic nerve function testing performed on 3/26/15 was not likely to have been more effective than other methods of evaluating this patient.  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 Upheld

Summary Reviewer 3


A 65-year-old female enrollee has requested reimbursement for autonomic nerve function testing performed on 3/26/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the superior efficacy of the services at issue has not been established.  The patients history is not well-documented and does not indicate features of neuropathy.  The examination was inadequate to discern if neuropathy was a realistic consideration. Electrodiagnostic test results were not submitted for review.  If small fiber neuropathy is within the differential, commonly such individuals would be assessed by a neurologist familiar with neuropathy, and undergo more detailed neurologic clinical examination.  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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer

The patient is a seven-year-old male with a history of constitutional delay of growth and development. The patient was born at 30 weeks gestational age after a pregnancy complicated by eclampsia, and emergency cesarean section secondary to fetal distress and maternal hypertension. The patients birth weight was three pounds two ounces. On 11/8/17, the provider noted that the patients bone age on 10/12/16 showed a bone age of four years six months, at a chronological age of six years two months. A later bone age study in November 2017, was five years six months, at a chronological age of seven years three months. The height is noted to be below the 1.2 percentile for age. The provider has recommended growth hormone therapy on the basis of idiopathic short stature. His parent has requested authorization and coverage for somatropin (Norditropin). The Health Insurer has denied this request indicating that the requested medication is not medically necessary. The patients growth velocity in November 2017 was stated as being an annualized 6.4 cm per year. His height standard deviation score is -2.4, putting him at the 0.9%. Using his last bone age the patients predicted adult height is approximately five feet, eight to nine inches. The genetic target for this patient is therefore likely five feet 9.25 inches, +/-4 inches. The normal laboratory data, bone age delay, and last calculated height velocity indicate that he has constitutional delay. However, exogenous growth hormone is not likely to be present so long as the patient maintains a normal height velocity. All told, the requested somatropin (Norditropin) is not supported as medically necessary for treatment of this patients medical condition.  Based on the foregoing discussion, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 56-year-old male enrollee has requested reimbursement for des-gamma-carboxy prothrombin (DCP) testing performed on the enrollee on 5/29/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that non-alcoholic steatohepatitis (NASH) can progress to hepatocellular carcinoma (HCC) (Yasui, et al). Yasui and colleagues performed a study to examine the clinical and pathological course of how NASH progresses to HCC. The authors found that NASH progressed to HCC after a median follow-up period of 3.8 years (range: 0.5-11.6 years). All patients had been identified as having HCC during screening, which included 12 patients assessed by ultrasound, four patients assessed with computerized tomography, two patients that underwent serum des-?-carboxy prothrombin testing and one patient that underwent serum a-fetoprotein testing. In addition, the meta-analysis by Bertino and colleagues resulted in the following conclusion A search of the literature was made using cancer literature and the PubMed database for the following keywords: markers and HCC, a-fetoprotein (AFP) and HCC, Des-?-carboxy prothrombin (DCP) and HCC, squamous cell carcinoma antigen-immunoglobulin M complexes (SCCA-IgM Cs). Despite the large number of studies devoted to the immunohistochemistry of HCC, at the present time, the absolute positive and negative markers for HCC are still lacking, and even those characterized by very high sensitivity and specificity do not have a universal diagnostic usefulness. In conclusion none of the three biomarkers (AFP, DCP, SCCA-IgM Cs) is optimal. Currently the recommended screening strategy for patients with cirrhosis includes the determination of serum AFP levels and an abdominal ultrasound every six months to detect HCC at an earlier stage. Given the above, the DCP testing performed on 5/29/15 has not been established as 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 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 Upheld

Summary Reviewer 2

A 56-year-old male enrollee has requested reimbursement for des-gamma-carboxy prothrombin (DCP) testing performed on the enrollee on 5/29/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that in patients with cirrhosis of liver, a combination of ultrasound of the liver and alpha-fetoprotein (AFP) are recommended for surveillance for hepatocellular carcinoma. Liver ultrasound is also recommended as the primary surveillance modality for HCC. Other tests that have been used and examined for HCC surveillance include DCP and lectin-bound AFP (AFP-L3%). The evidence is inconclusive about whether these biomarkers perform better than AFP for detecting HCC. AFP was found to be more sensitive than DCP and AFP-L3% for the diagnosis of early stage HCC at a new cutoff of 10.9?ng/ml (Marrero et al). A combination of these markers (AFP, AFP-L3, DCP) only marginally improves the accuracy for early detection of HCC (Carr, et al). Therefore, at this point, the use of DCP has not been established as 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 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 Upheld

Summary Reviewer 3

A 56-year-old male enrollee has requested reimbursement for des-gamma-carboxy prothrombin (DCP) testing performed on the enrollee on 5/29/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that patients with cirrhosis are at risk for hepatocellular carcinoma (Mancebo, et al).  Guidelines from the American Association for the Study of Liver Disease (AASLD) recommend screening every six months in patients with cirrhosis due to the risk of developing hepatocellular carcinoma (Bruix and Sherman). Surveillance ultrasound and alpha-fetoprotein (AFP), which are screening modalities for hepatocellular carcinoma in patients with cirrhosis, have sensitivities of only 44% and 66%, respectively (Singal, et al). Clinical studies show that hepatocellular carcinoma can present with positive AFP, AFP subtype L3, or des gamma carboxy prothrombin (DCP) with only some overlap (Li and Satomura). DCP is an effective marker for the development and progression of hepatocellular carcinoma (Durazo, et al; Yuen and Lai).  For these reasons, the DCP testing performed on 5/29/15 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 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 Upheld

Summary Reviewer 


A 54-year-old male enrollee has requested authorization and coverage for Repatha. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has been assessed with cardiovascular disease. The physician reviewer found that the documentation provided does not support the requested medication in this clinical setting.  The patient has been diagnosed with hyperlipidemia with no documented clinical cardiovascular events or significant carotid stenosis. The records do document intolerance to one statin medication (simvastatin). Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL-cholesterol (Sabatine, et al; Robinson, et al). The records submitted do not support the criteria as outlined by the literature.  Studies are lacking to support the use of PCSK9 inhibitors in other patient populations such as this patient. In addition, current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting (Stone, et al). All told, Repatha is not medically necessary for the treatment of this patient. Therefore, based on the above, the requested medication is 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

A 29-year-old female enrollee has requested authorization and coverage for the LINX procedure. 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 a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. Skubleny and colleagues concluded, aLong-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation.a Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia, requiring endoscopic intervention. Sheu and Rattner concluded, aThe long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined.a LINX has significant potential adverse effects and can be associated with poor outcomes. Therefore, the requested LINX procedure is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 29-year-old female enrollee has requested authorization and coverage for the LINX procedure. 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 only partially responded to medical therapy with acid suppressive medication. The LINX Reflux Management System has been shown to be superior to twice-daily proton pump inhibitor (PPI) therapy. Bell and colleagues noted that the LINX Reflux Management System normalized the total number of reflux episodes and acid exposure in 91 and 89 percent of patients, compared with 58 and 75 percent of those treated with twice-daily PPIs. The LINX Reflux Management System has been compared with laparoscopic Nissen fundoplication in several meta-analyses. Clinical control of reflux was comparable after the two procedures. In the study by Ganz and colleagues, the long-term safety and efficacy of the LINX prosthesis was evaluated in a prospective single-group trial of 100 patients with long-standing gastroesophageal reflux disease. At five years after LINX implantation, significantly fewer patients reported moderate or severe heartburn (12 versus 89 percent), moderate or severe regurgitation (1 versus 57 percent), bothersome gas-bloat (8 versus 52 percent), and daily PPI use (15 versus 100 percent). GERD-related quality of life was also better. There is sufficient support for the requested services in this clinical setting. Therefore, the requested LINX procedure is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 29-year-old female enrollee has requested authorization and coverage for the LINX procedure. 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 LINX Reflux Management System works by augmenting the lower esophageal sphincter with a ring of magnets. Eligible patients must demonstrate typical gastroesophageal reflux disease symptoms, an abnormal pH study, partial response to daily proton pump inhibitor (PPI) therapy, and absence of a large hiatal hernia or severe esophagitis. This patient meets all of these criteria. In the study by Ganz and colleagues, the long-term safety and efficacy of the LINX prosthesis was evaluated in a prospective single-group trial of 100 patients with longstanding gastroesophageal reflux disease. At five years after LINX, significantly fewer patients reported moderate or severe heartburn (12 versus 89 percent), moderate or severe regurgitation (1 versus 57 percent), bothersome gas-bloat (8 versus 52 percent), and daily PPI use (15 versus 100 percent). No device erosions, migrations, or malfunctions occurred. The ability to belch or vomit, when needed, was preserved in all patients. The medical evidence supports the requested services in this patientas case. Therefore, the requested LINX procedure is likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 23-year-old male enrollee has requested reimbursement for physical therapy performed from 7/14/15 through 10/31/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees chronic pelvic pain syndrome. The physician reviewer found the services at issue were not medically necessary for treatment of his medical condition. The standard for outpatient physical therapy in treatment of pelvic pain and urinary or defecatory dysfunction is through the use of various modalities and techniques which are utilized to decrease pain and to rehabilitate the intrinsic pelvic floor musculature and extrinsic musculature of the lumbosacral spine. These various modalities increase the patients awareness and voluntary control of these muscles, while educating the patient on proper bowel/bladder techniques and habits. The standard course of physical therapy would include an initial trial of eight treatments. If there was benefit to the patient, an additional 16 treatments could be considered. After the initial physical therapy, transition to an independent exercise program would be expected with a fading of skilled therapy treatments. If there was a lack of improvement, then a reevaluation in terms of reasonable therapy goals or consideration of further medical workup would be the expected management. In this case, the number of therapies that were provided from 7/14/15 through 10/31/15 exceeded the standard number of treatments. 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 28-year-old male enrollee has requested reimbursement for CPT code 29879 performed on 2/12/19. 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 the submitted documentation supports the medical necessity of the services at issue. This patient sustained a skiing injury to his left knee. The initial diagnosis on 1/23/19 was lateral meniscus tear and possible ACL graft laxity. Additionally, there was a possible chondral injury, loose body, and chondromalacia. On 2/12/19, the patient underwent surgery, which consisted of left knee arthroscopy, repair of anterior cruciate graft, partial medial and partial lateral meniscectomies, removal of multiple loose bodies, abrasion chondroplasty of the lateral femoral condyle, and peripheral nerve blocks. The operative report documents a large articular defect of the lateral femoral condyle treated by abrasion chondroplasty down to bleeding bone. The medical evidence supports abrasion chondroplasty in this clinical setting. Studies have revealed good results with both mechanical chondroplasty and radiofrequency chondroplasty upon follow-up for four years. Therefore, CPT code 29879 performed on 2/12/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 57-year-old male enrollee has requested authorization and coverage for Praluent. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees coronary artery disease status post drug eluting stent (DES) placement. The physician reviewer found that the documentation provided for review establishes that this patient has severe multi-vessel coronary artery disease. He is currently being treated with ezetimibe, but his LDL cholesterol is still not at goal. His most recent LDL cholesterol was 91, which is over the target range of less than 70. He was intolerant of both simvastatin and pravastatin due to muscle pain and fatigue. Thus, he meets all of the criteria for treatment with Praluent. The use of Praluent in this instance is clinically indicated and is supported by published guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) (Grundy, et al; Rosenson, et al). Given this support, the requested Praluent is medically necessary for treatment of this patients severe, multi-vessel coronary artery disease. Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.