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

Summary Reviewer 1

A 42-year-old male enrollee has requested authorization and coverage for an implanted neurostimulator pulse generator system. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees obstructive sleep apnea (OSA). The physician reviewer found that the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) considers upper airway stimulation via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with CPAP therapy. This patients clinical examination shows the tonsils present with elongation and redundancy of the soft palate. This was documented on the drug induced sleep endoscopy with the recommendation that the patient consider mandibular advancement procedures. Although the patient meets certain clinical criteria for implantation of a hypoglossal nerve stimulator with a body mass index (BMI) of less than 32 and positive evaluation by drug induced sleep endoscopy, the patient has not been offered other potential surgical options such as uvulopalatopharyngoplasty (UPPP) and the clinical status of the patients results of additional CPAP titrations studies are unknown. Overall, other procedures are likely to provide this patient with improvement in symptoms beyond that expected with hypoglossal nerve stimulation. Thus, the requested implanted neurostimulator pulse generator system 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, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 42-year-old male enrollee has requested authorization and coverage for an implanted neurostimulator pulse generator system. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees obstructive sleep apnea (OSA). The physician reviewer found that as noted in the medical literature, OSA is an increasingly prevalent clinical problem with significant effects. CPAP has demonstrated excellent efficacy and low morbidity with long-term adherence rates approaching 50%. Upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. Woodson and colleagues reported that the STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. This trial demonstrated the hypoglossal nerve stimulator to be safe and effective in a small subset of patients with OSA who have failed CPAP, with an AHI median value of 28.2 event per hour, a BMI less than 32, and nonconcentric airway collapse. However with an AHI of 61.1, this patient does not meet the criteria. For these reasons, the requested implanted neurostimulator pulse generator system 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, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 42-year-old male enrollee has requested authorization and coverage for an implanted neurostimulator pulse generator system. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees obstructive sleep apnea (OSA). The physician reviewer found that Hypoglossal nerve stimulation is an emerging technology for the treatment of OSA. While initial studies have shown promise, conclusions cannot be drawn from the available evidence. The optimal patient selection criteria for the use of hypoglossal nerve stimulation has not been defined nor have the findings of the original studies been replicated. At this time, the practice guidelines on the management of OSA do not recommend the use of hypoglossal nerve simulator. All told, the requested implantation of a hypoglossal nerve simulator for treatment of this patients OSA 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, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 62-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/02/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found the medical evidence supports the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with 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 8/02/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found the current literature supports the service at issue 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 noted integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Thus, digital breast tomosynthesis performed on 8/02/16 was likely to have been of greater benefit than 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 8/02/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, there were no problems to be resolved.  The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications.  A routine mammogram would have been sufficient in this clinical setting.  Breast tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to multiple prior mammograms.  Thus, digital breast tomosynthesis performed on 8/02/16 was not likely to have been superior over other methods of evaluating this patient.  Based upon the information set forth above, the service 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 Upheld

Summary Reviewer 


A 63-year-old male enrollee has requested reimbursement for an unlisted chemistry procedure performed on 7/27/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees malignant 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 has also been thought to add to these statistics. By Balch staging, this melanoma would be classified as a T1a, or stage 1A. As such, this patient would be expected to have at least an 88% ten-year survival. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either Class I (90 to 92% five-year recurrence-free survival), or Class II (48 to 77% five-year recurrence-free survival). Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients undergoing sentinel node sampling. Berger and colleagues reported on 156 cases, but there was not sufficient follow-up to determine the actual value of the test. It is not clear how the five-year DecisionDx-Melanoma data compares to the Balch ten-year data. Most importantly, it is unproven as to whether the DecisionDx-Melanoma classification can be used to make clinical decisions, especially in patients with stage 1A disease. The current medical evidence does not support the services at issue in this clinical setting. All told, unlisted chemistry procedure performed on 7/27/17 was not medically necessary for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 50-year-old female enrollee has requested reimbursement for anesthesia services provided on 9/29/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees risk for colon cancer.   The physician reviewer found the patient sites a rationale of malignant hyperthermia as a reason for the monitored anesthesia care used for the colonoscopy and endoscopy. However, the routine sedation for these procedures is not a contraindication for a history of malignant hyperthermia. General anesthesia is not needed for colonoscopy and therefore, this procedure is not at risk of provoking a malignant hyperthermia crisis. The patient is otherwise healthy and does not meet criteria for the use of monitored anesthesia care for colonoscopy or endoscopy. All told, the monitored anesthesia care services provided on 9/29/14 were not medically necessary for evaluation of this patients medical condition. Based on the foregoing discussion, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 26-year-old male enrollee has requested reimbursement for the substance use residential treatment services provided from 11/11/14 through 11/19/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse.  The physician reviewer found that the records indicate that this patient was not at imminent risk for withdrawals. He was not suicidal or homicidal and he was not aggressive towards others. He did not show self-harm behaviors. He was cognitively intact and able to perform activities of daily living. He was medically and psychiatrically stable. He was motivated and a willing participant in his recovery. While he remained at risk for relapse, he had improved and treatment could have been managed at a lower level of care. By 11/11/14, he no longer required 24-hour supervision and could have been stepped down to a lower level of care such as intensive outpatient. For these reasons, the substance use residential treatment services provided from 11/11/14 through 11/19/14 were not medically necessary for treatment of this patients medical condition. Therefore, 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 Upheld

Summary Reviewer 

The patient is a 52-year-old female with a past history of long-term eating disorder, laxative abuse, chronic hyponatremia, hypercoagulable state treated with Pradaxa, and deep vein thrombosis who presented to the hospital in hypovolemic shock secondary to upper gastrointestinal bleed. She was hypotensive, with systolic blood pressure in the 60s and tachycardia. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient was able to ambulate to the stretcher. There is no documentation of frequent turning of the patient or hourly fingerstick blood glucose levels. There is no documentation of the necessity for intravenous fluids or the necessity for intravenous medication. Furthermore, there is documentation that the patient has had treatment multiple treatments at this facility in addition to other facilities, but this is a facility that she was agreeable to. There is no documentation of exceptional factors supporting medical necessity for this facility rather than alternative facilities with closer geographic proximity. Therefore, A0426, A0430, A0435, A0434 for date of service 6/22/19 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 42-year-old female enrollee has requested authorization and coverage for anterior cervical discectomy and fusion surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. The records document a history of neck pain and radicular paresthesias in the upper extremities, left greater than right, in the C6 distribution, and imaging evidence corroborates the clinical findings. Epidural steroid injections provided short-term relief. The provider has recommended an anterior cervical discectomy and fusion at C5-6. Anterior cervical discectomy and fusion is one of the most common procedures performed in spine surgery. The indication is neck pain with a neurocompressive lesion, as in this case. It allows for a direct decompression of the spinal cord and the neural foramina. Various studies comparing anterior cervical discectomy and fusion with anterior plate fixation versus use of cages report superior surgical outcomes in anterior cervical discectomy and fusion procedures with anterior plate fixation and slightly better neck pain scores at last follow-up. There were no significant differences in the operative blood loss, clinical outcomes or rates of fusion between the two groups. The medical evidence supports the requested services in this patients case. Therefore, anterior cervical discectomy and fusion at C5-6 level is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a five-year old male who has been diagnosed with autism spectrum disorder. . The patientas parent has requested reimbursement and prospective authorization and coverage for applied behavior analysis (43.5 hours per week of code 97135 and 18 hours per month of code 97155) provided from 10/06/20 through 4/06/21. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary. The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue. Based on the submitted documentation, 40 hours per week of 97135 are medically necessary and 16 hours per month of code 97155 are medically necessary. Per the records, the patient is actively working on goals. In an undated letter, the patientas provider requested 40 hours of one-to-one applied behavior analysis, which is well within current treatment guidelines. Behavior Analyst Certification Board guidelines note, aTreatment hours are subsequently increased or decreased based on the clientas response to treatment and current needs. Hours may be increased to more efficiently reach treatment goals. Decreases in hours of therapy per week typically occur when a client has met a majority of the treatment goals and is moving toward discharge.a As this patient is actively work on goals, is making progress, and is not yet ready for discharge, 40 hours per week of code 97135 is appropriate. Additionally, the request for 40 hours of code 97135 per week meets the medical necessity criteria set by Papatola and Lustig. Their definition includes ahealth-care services that a provider, exercising a 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.a Applied behavior analysis is the most effective treatment for autism, thus is essential to meet the patientas needs. Similarly, applied behavior analysis is consistent with the diagnosis of autism. With regard to code 97155, 16 hours per month is medically appropriate, as this is 10% of the one-to-one applied behavior analysis which will be provided. Therefore, 40 hours per week of code 97135 and 16 hours per month of code 97155 from 10/06/20 through 4/06/21 were and are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 33-year-old female enrollee has requested reimbursement for gene testing (BRAF mutation analysis) provided on 11/19/15. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees papillary thyroid carcinoma. The physician reviewer found the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is insufficient support in the peer-reviewed medical literature for the testing at issue in this clinical setting. The National Comprehensive Cancer Network (NCCN) guidelines classify molecular profile testing as category 2B, based upon lower level evidence. Given the lack of sufficient support per national guidelines, the gene testing (BRAF mutation analysis) provided on 11/19/15 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 Overturned

Summary Reviewer 2


A 33-year-old female enrollee has requested reimbursement for gene testing (BRAF mutation analysis) provided on 11/19/15. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees papillary thyroid carcinoma. The physician reviewer found the gene testing (BRAF mutation analysis) provided on 11/19/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The testing at issue is considered the standard of care in the evaluation of thyroid nodules. BRAF mutation analysis provides prognostic information and may help guide therapy decision making regarding use of BRAF inhibitor therapy. Identifying a marker may open other treatment options or allow for enrollment in clinical trials. Therefore, the testing at issue 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 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 33-year-old female enrollee has requested reimbursement for gene testing (BRAF mutation analysis) provided on 11/19/15. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees papillary thyroid carcinoma. The physician reviewer found the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Papillary thyroid cancer is a frequent histologic subtype of thyroid cancer. The genetics can be complex and the BRAF mutations are frequent. This is notable since the presence of the mutation provides significant prognostic information (Fraser, et al; Lee, et al; Kim, et al). The medical literature supports a role for BRAF mutational testing in this clinical setting. Accordingly, the gene testing (BRAF mutation analysis) provided on 11/19/15 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 testing 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.