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

Summary Reviewer 1


A 32-year-old female enrollee has requested reimbursement for the laboratory testing provided on 6/6/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees miscarriage. The physician reviewer found that there are many causes of recurrent pregnancy loss including parental genetic abnormalities, uterine abnormalities and thyroid dysfunction. While some forms of autoimmune disease, such as antiphospholipid syndrome, have been associated with poor pregnancy outcomes, the role of thrombophilias remains less clear (Kaiser and Branch). The American College of Obstetricians and Gynecologists (ACOG) states that whereas meta-analyses and a retrospective cohort study have revealed an association between inherited thrombophilias and first-trimester pregnancy loss, prospective cohort studies have found no association between inherited thrombophilias and fetal loss. Accordingly, the testing done for serum homocysteine, Factor V Leiden, protein C activity, protein S activity, MTHFR, and prothrombin C20210A mutation was not medically indicated. Thus, the laboratory testing provided on 6/6/16 was 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, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


A 32-year-old female enrollee has requested reimbursement for the laboratory testing provided on 6/6/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees miscarriage. The physician reviewer found that this patient had two very early pregnancy losses, and underwent an extensive work-up with multiple blood tests including a number of inherited thrombophilias. According to the American College of Obstetricians and Gynecologists (ACOG) guidelines on inherited thrombophilias a definitive causal link cannot be made between inherited thrombophilias and adverse pregnancy outcomes. The ACOG further noted that prospective cohort studies have found no association between inherited thrombophilias and fetal loss. All told, there is a lack of peer-reviewed medical literature or published guidelines to demonstrate that the laboratory testing provided on 6/6/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was 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 32-year-old female enrollee has requested reimbursement for the laboratory testing provided on 6/6/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees miscarriage. The physician reviewer found that the laboratory studies that were ordered for this patient have not been recommended by American College of Obstetricians and Gynecologists (ACOG) as beneficial for patients who have had first trimester pregnancy loss. Further, the use of anticoagulation, aspirin, or both has not been shown to reduce the risk of early pregnancy loss in women with thrombophilias. Since there is no effective treatment associated with identification of abnormalities in these laboratory studies, there is no benefit to the patient in obtaining the studies. Thus, the laboratory testing provided on 6/6/16 was 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, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 49-year-old male enrollee has requested reimbursement for short-term rehabilitation services provided on 6/3/16, 6/16/16, 8/12/16, 9/9/16, 9/30/16 and 11/23/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees low back pain. The physician reviewer found that the short-term rehabilitation consisting of the EMS (CPT 97014) services provided on 6/3/16, 6/16/16, 8/12/16, 9/9/16, 9/30/16 and 11/23/16 were medically necessary for treatment of the patients medical condition. The EMS was clinically indicated for treatment of the patients neck, low back, and hip pain. However, the remaining short term rehabilitation services provided on 6/3/16, 6/16/16, 8/12/16, 9/9/16, 9/30/16 and 11/23/16 were not medically necessary. There is a lack of functional deficit documentation to support extraspinal manipulation and intersegmental traction. In general, mechanical traction is recommended for patients with radiculopathy diagnosis in conjunction with other treatment such as exercises, if there are documented failure of other evidence-based therapeutic procedures to resolve symptoms 18 after three weeks. In this case, there is a lack of documentation demonstrating documented failure of such treatments. Therefore, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 32-year-old female enrollee has requested authorization and coverage for bilateral breast reduction surgery. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees macromastia.   The physician reviewer found this patient satisfies the criteria from the American Society of Plastic Surgeons (ASPS) for the requested bilateral breast reduction surgery but not the requested suction assisted lipectomy. In the peer-reviewed medical literature, Coriddi and colleagues noted that documentation of a functional problem can be demonstrated with evidence of intertriginous infections, back and shoulder pain, shoulder notching, physical inactivity, dissatisfaction with breast appearance, poor sexual well-being, and poor psychosocial well-being. This patient has well-documented chronic back pain, neck pain, shoulder pain, breast pain, shoulder grooving, and intermittent intertrigo with failure of topical medical management and other reasonable conservative management including analgesics. Further, her symptomatic macromastia has failed reasonable conservative management. Her photographs are supportive of her clinical functional deficit. Based on this, her condition of macromastia is causing functional problems that would benefit significantly from reduction surgery. All told, breast reduction is well-known to be safe in the carefully selected patient and is appropriate based on the ASPS criteria for this patient. However, this is not the case for suction assisted lipectomy which is generally performed to improve the aesthetic appearance of the breasts. Based on the foregoing discussion, a portion of the requested services is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 51-year-old male has requested reimbursement for gene expression profiling performed on 5/04/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add a bit more to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. The melanoma is then classified based on the risk of metastasis. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients undergoing sentinel node biopsy. At this time, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year data of Balch. Based on the medical evidence, it is unclear whether DecisionDx-Melanoma data can be used to make clinical decisions. Therefore, gene expression profiling performed on 5/04/17 was not likely to have been of greater benefit 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 2

A 51-year-old male has requested reimbursement for gene expression profiling performed on 5/04/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that there is a lack of support for the services at issue in this patients case. There is a lack of evidence from the literature that tailored follow-up according to these test results has an impact on long-term outcomes. Prospective randomized studies to determine recurrence risk is lacking for this test. The medical evidence has not determined the superior efficacy of the services at issue. Thus, gene expression profiling performed on 5/04/17 was not likely to have been of greater benefit 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 51-year-old male has requested reimbursement for gene expression profiling performed on 5/04/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that this patient has an early stage melanoma. The National Comprehensive Cancer Network (NCCN) guidelines states that while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of this testing was not likely to have altered treatment and surveillance recommendations. In sum, the superior effectiveness of gene expression profiling performed on 5/04/17 has not been established. 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 Overturned

Summary Reviewer 

The patient is a 58-year-old man with type 2 diabetes. The patient has requested authorization and coverage for Ozempic 2 mg/1.5 mL pen injectors. 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 Ozempic is a member of  the glucagon-like peptide 1 (GLP-1) analogs, a new class of drugs used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1. This class of medications has shown significant improvements in glycemic control, progressive weight loss, low incidence of hypoglycemia and potential improvement of cardiovascular risk factors. Additionally, recent studies have demonstrated a significantly lower rate of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke among patients receiving Ozempic. Based on the submitted records, this patient is an excellent candidate for Ozempic. Therefore, Ozempic 2 mg/1.5 mL pen injectors are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 62-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 3/31/16.  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 patient is a 62-year-old asymptomatic female who was evaluated with screening mammogram and digital breast tomosynthesis on 3/31/16. The patient reported a positive family history for breast cancer. The patient also felt a lump in her right breast. She had bilateral mammography including breast tomosynthesis which revealed vague density requiring further ultrasound evaluation. The studies showed no mass. The patient has requested reimbursement for the breast tomosynthesis portion of her examination. The Health Insurer has denied reimbursement for digital breast tomosynthesis performed on 3/31/16.  Per the Health Insurer, the service at issue was investigational for the evaluation of this patient. There is evidenced base support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely to be more effective than had her examination been performed using two dimensional imaging alone. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 62-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 3/31/16.  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 This patient is a 62-year-old female who had a bilateral screening mammogram with tomosynthesis on 3/31/16. The patient reported a positive family history of breast cancer in her maternal grandmother, and in her maternal and paternal aunts. The patient presented for a breast screening examination on 3/31/16. The patients breast was noted with scattered fibroglandular densities in the right breast. The ultrasound showed small cysts. The Health Insurer has denied the tomosynthesis portion of the exam. The patient has appealed the denial and this denial is the subject of this appeal and determination.
The medical literature supports breast tomosynthesis in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus the literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis performed on 3/31/16 was likely to have been superior to other methods of evaluating this patient. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 62-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 3/31/16.  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 patient is a 62-year-old female who had a screening mammogram including tomosynthesis on 3/31/16. The patient relayed a complaint of a palpable breast mass.  The report noted no evidence of breast cancer. The Health Insurer has denied reimbursement for digital breast tomosynthesis performed on 3/31/16. Per the Health Insurer, the service at issue was investigational for the evaluation of this patient.
There is sufficient support for digital breast tomosynthesis for the evaluation of this patient. The medical studies have shown that the addition of three dimensional digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 29-year-old female enrollee has requested authorization and coverage for lumbar spine magnetic resonance imaging. 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 the submitted documentation supports the medical necessity of the requested services. This patient has a progressive problem related to her lumbar spine. While she has intact reflexes and no red flags, she has completed a six-week course of physical therapy, and still has symptoms. Because her symptoms have worsened since her MRI in 2010 and she has completed a supervised six-week course of physical therapy in June and July 2019 without relief, MRI of the lumbar spine is medically appropriate. Therefore, the requested lumbar spine MRI 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 Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. According to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for treating hepatitis C, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. The peer-reviewed literature does not support denying treatment for HCV because the patient does not have an advanced stage disease. Moreover, the AASLD and IDSA recommendations for treating HCV recommend a daily fixed-dose combination of ledipasvir/sofosbuvir (Harvoni) for treatment-naive patients with HCV genotype 1 infection. Therefore, the request for Harvoni is medically necessary for treatment of the patients HCV. For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 32-year-old male enrollee has requested reimbursement for residential treatment center (RTC) services provided from 6/11/17 through 7/2/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found that the medical records provided for review do not support the medical necessity of the RTC services provided from 6/11/17 through 7/2/17 for treatment of this patients behavioral health issues. On 5/27/17 admission, the patients symptoms prevented him from functioning properly. However, by 6/11/17, the patient was not an imminent danger to self or others, and he was not gravely disabled. He was performing his activities of daily living independently. He continued to endorse passive suicidal ideation without intent, as well as anxiety and depression. He continued to report auditory and visual hallucinations, which the records suggest are the patients baseline. His psychotic symptoms were stabilized on Clozaril 500 mg, which had been titrated up from 300 mg. Further, Clozaril titration does not require a RTC setting and can be performed in the outpatient setting. His other medications were unchanged, and he was compliant. His family and girlfriend provided a safe and supportive environment. He no longer required 24-hour monitoring in the RTC setting, and could have continued treatment at IOP level of care. Thus, the RTC services provided from 6/11/17 through 7/2/17 were not medically necessary. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The patient is a 64-year-old female with a history of transient ischemic attacks characterized by headache, dizziness, and blurred vision. She has hypertension and is neurologically intact.  She is currently being treated with aspirin and Plavix.  On 2/27/18, she underwent left internal carotid artery angioplasty and stenting. Cerebral perfusion study showed diminished perfusion in the region of the right posterior cerebral artery. The patient has requested coverage for vertebral artery angioplasty. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient. There is sufficient support for the requested services in this patients case. There is a demonstrated cause of the transient ischemic attacks. The records document right vertebral artery stenosis of a significant degree. The patient is at high risk for a brainstem stroke. She has not responded to pharmacological therapy. Therefore, the requested vertebral artery angioplasty is likely to be of greater benefit than other treatment options. Based upon the information set forth above, 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.