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

Summary Reviewer 


The parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for mental health residential treatment services provided from 4/9/14 forward. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse and parent-child relational problem.  The physician reviewer found that the records submitted for review indicate that the patient had a significant substance abuse history and he had just gone away without leave from his previous placement. However, there is no indication that placement in this facility was geared to address motivational concerns or that the patient had any symptoms requiring 24-hour support and intervention. According to the American Psychiatric Association (APA) practice guidelines, patients with substance use disorders should be treated in the least restrictive setting which is likely to be safe and effective. There is a lack of evidence that this patients substance abuse presented an imminent safety risk or that he could not have been managed effectively on an ambulatory basis. Further, there is no documentation of withdrawal symptoms. Overall, the chart reviewed fails to support the medical necessity of residential substance abuse services from 4/9/14 through 10/19/14 and ongoing. Based on the foregoing discussion, I have concluded that the services at issue were not and are 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 

A 63-year-old male enrollee has requested reimbursement for the prostate ablation performed on 10/24/17. The Health Insurer has denied this request indicating that the procedure at issue was not medically necessary for treatment of the enrollees prostate cancer. The physician reviewer found that in the peer-reviewed medical literature, Tay and colleagues concluded that, focused ultrasound is technically feasible for focal prostate ablation and appears to have a favorable early safety and functional profile. However, the authors cautioned that further clinical trials are necessary to establish oncologic efficacy. Moreover, there is a lack of current data demonstrating that HIFU provides improved long-term benefits over active surveillance in patients with low-grade and low-stage prostate cancer. Given the recommendations based on the current scientific evidence, the prostate ablation performed on 10/24/17 was not medically necessary for treatment of this patients prostate cancer. Based on the foregoing discussion, the procedure at issue was 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 42-year-old female enrollee has requested authorization and coverage for bilateral reduction mammoplasty. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees symptomatic bilateral macromastia. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested services. According to American Society of Plastic Surgeons (ASPS) Symptomatic breast hypertrophy is defined as a syndrome of persistent neck and shoulder pain, painful shoulder grooving from brassiere straps, chronic intertriginous rash of the inframammary fold, and frequent episodes of headache, backache, and neuropathies caused by heavy breasts caused by an increase in the volume and weight of breast tissue beyond normal proportions. ASPS further state that based on the results of Level I and II Evidence, reduction mammaplasty has been proven effective at reducing macromastia related symptoms and improving postoperative quality of life. In this case, the patient has severe symptomatic macromastia that has failed reasonable conservative measures. Her physical examination was consistent with significant macromastia that was supported by photographs showing significant shoulder grooving as well. The patient has documented back and shoulder pain, as well as shoulder grooving from bra straps. In addition, she has documented recurrent rashes that have failed conservative measures. Given the documentation submitted for review, the patient has a functional deficit directly related to macromastia that has failed conservative management and would likely improve with surgical correction. Therefore, bilateral reduction mammoplasty is medically necessary in this clinical setting. For the reasons provided, the requested services 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 

The parent of a 15-year-old male enrollee has requested reimbursement for residential substance use disorders treatment provided from 8/21/18 through 9/03/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. In terms of risk of harm, the records support a score of 1. The medical records indicate that the patient was not actively or passively suicidal. There were no reports of self-harm, and his risk of suicide was continuously rated as none. With regards to functional status, the records support a score of 2. The patient had some issues with level of function due to mental illness and relational issues, but overall showed appropriate daily functioning while in treatment. In terms of comorbidity, the records support a score of 1. The patient does not have a history of past medical issues. His last substance use was several months prior to the disputed timeframe. With regards to level of stress of the recovery environment, the records support a score of 2. The patient was noted to have a safe and sober living situation. In terms of level of support of the recovery environment, the records support a score of 2. The patients family was involved in treatment. With regards to resiliency and treatment history, the records support a score of 3. It appears that the patient had good response to the five months in the residential treatment center as evidenced by stable mood, cooperation in therapy, sobriety and insight into his need for treatment. In terms of acceptance and engagement of the patient, the records support a score of 2. The patient actively participated in therapy, and he was cooperative with consistent engagement. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with staff. Thus, the patient has a composite score of 15. This score correlates with outpatient services. Therefore, residential substance use disorders treatment provided from 8/21/18 through 9/03/18 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 55-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 according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) 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. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. In addition, AASLD/IDSA treatment guidelines recommend Harvoni for 12 weeks for treatment-naive patients with HCV genotype 1 infection. Therefore, based on national guidelines Harvoni is medically necessary in this clinical setting.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 Overturned

Summary Reviewer 

An 18-year-old female enrollee has requested reimbursement for residential treatment provided from 9/11/19 through 9/15/19. 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 the Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. In terms of risk of harm, the records support a score of 4 due to signs of consistent deficits in ability to care for self, as evidenced by the patients continued restriction of food intake, leading to lack of desired weight gain. With regard to functional impairment, the records support a score of 3. The patient had moderate functional impairment. In terms of comorbidity, the records support a score of 4. The patient failed to achieve full weight restoration and she had primary amenorrhea. With regard to level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful recovery environment, due to conflict with her parents regarding her eating, as well as the disruptions to her social and educational activities caused by her need for intensive treatment. In terms of level of support of the recovery environment, the records support a score of 2 due to the parents active participation in treatment. With regard to resiliency and treatment history, the records support a score of 4 due to persistence of disordered eating despite extensive prior treatment exposure at various levels of care. In terms of treatment acceptant and engagement of the patient, the records support a score of 3. The patient was incompletely engaged, due to her minimization of the seriousness of her disordered eating and her struggles to comply with her food plan. Therefore, the records support a total score of 22. Due to serious risk of harm, the recommended level of care is level five medically monitored residence-based services. Therefore, residential treatment provided from 9/11/19 through 9/15/19 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 19-year-old female enrollee has requested reimbursement for the Anser IFX test provided on 2/16/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found that the Prometheus Anser IFX test is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies. Some evidence exists that low serum levels of infliximab the presence of antibodies to infliximab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear with continued treatment. The reasons for therapeutic failures remain unclear.  However, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al). Currently, it has not been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established, as appears to apply in this case to this patients asymptomatic setting at the time of Anser testing. For these reasons, the Anser IFX test provided on 2/16/16 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 19-year-old female enrollee has requested reimbursement for the Anser IFX test provided on 2/16/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found that in this case, Anser IFX was ordered to determine infliximab level and whether antibodies to Remicade were present. Loss of response to infliximab can occur for many reasons, although there was not a clear loss of response to infliximab in this case (Mahadevan, et al). In addition, the presence of antibodies alone has not been proven to result in loss of response to infliximab or infusion reactions, nor have threshold levels been established (Steenholdt, et al). Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response (Vande Casteele, et al; Nanda, et al). One study, with some patients undergoing dose intensification following initial non-response, showed no difference in serum levels of infliximab between patients who responded to dose intensification versus those who did not (Pariente, et al). In summary, the current medical literature lacks high-quality controlled studies to define drug level or antibody level thresholds requiring action, compare clinical strategies based on those thresholds, and then definitively establish that use of Anser IFX improves outcome when used in those treatment pathways. Given these findings, the Anser IFX test provided on 2/16/16 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 3

A 19-year-old female enrollee has requested reimbursement for the Anser IFX test provided on 2/16/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found that monitoring patients on infliximab with measurement of infliximab levels and antibodies to infliximab continues to be an area of intense investigation. In general, infliximab levels correlate inversely with disease activity. However there is a lack of controlled data which have identified the optimal drug level. Further, categorization of drug levels as high or low and antibody levels as high or low has not been validated using prospectively controlled data. All told, the Anser IFX test provided on 2/16/16 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 Upheld

Summary Reviewer 

A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma assay performed on 12/28/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees melanoma. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. This patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines state 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 the DecisionDx-Melanoma assay were not likely to have altered treatment and surveillance recommendations. Thus, DecisionDx-Melanoma assay performed on 12/28/17 was not medically necessary for the evaluation of the enrollees medical condition. 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 41-year-old male enrollee has requested authorization and coverage for CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. The U.S. Food and Drug Administration has approved the LINX device for patients with diagnosed gastroesophageal reflux disease as defined by abnormal pH testing, and who continue to have chronic gastroesophageal reflux disease symptoms despite maximal medical therapy for the treatment of reflux. This patient has gastroesophageal reflux as based on pH recording. However, it appears he has benefited substantially from pantoprazole, and symptoms of gastroesophageal reflux disease recur when he discontinues this drug. As such, he cannot be considered refractory to medical management. Given this patients excellent response and tolerance to conventional acid suppression medication and the attendant surgical risks of LINX implantation, the requested CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure) is not likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 41-year-old male enrollee has requested authorization and coverage for CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the U.S. Food and Drug Administration has approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm. This patient meets those specific criteria. Based upon a prospective study by Lipham and colleagues that included 44 patients, the mean total percent time pH was less than 4 was reduced from 11.9 percent at baseline to 3.8 percent at three years. Reynolds and colleagues performed a study comparing the LINX procedure with laparoscopic fundoplication. The authors found that patients with gastroesophageal reflux disease had similar control of reflux symptoms after both LINX and fundoplication. The inabilities to belch and vomit were significantly fewer with LINX, along with a significantly lower incidence of severe gas-bloat symptoms. Finally, a five-year cohort data by Ganz and colleagues established the durability of the device. In a group of 85 patients, augmentation of the lower esophageal sphincter with a magnetic device provided significant and sustained control of reflux, with minimal side effects or complications. The authors noted that no new safety risks emerged over a five-year follow-up period. All told, CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure) is likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 41-year-old male enrollee has requested authorization and coverage for CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees 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. Per Katz and colleagues, 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, Long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. Sheu and Rattner concluded, The long-term safety and efficacy of LINX, both alone and in comparison to current gastroesophageal reflux disease therapies, remains to be determined. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. Thus, CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure) is not likely to be more beneficial than other available treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 57-year-old female enrollee has requested reimbursement and prospective authorization and coverage for Opsumit provided from 4/22/15 forward. The Health Insurer has denied this request indicating that the medication at issue was not and is not medically necessary for treatment of the enrollees pulmonary arterial hypertension. The physician reviewer found Tracleer was the first endothelin receptor antagonist that was U.S. Food and Drug Administration (FDA) approved for the treatment of primary pulmonary hypertension. Letairis and Opsumit are other endothelin receptor antagonists that gained FDA approval in 2007 and 2013, respectively. Based on the FDA approvals, each of these medications has a similar profile and potential side effects. The FDA notes that each of the medications can cause liver damage and liver function has to be monitored. Each of these medications can cause fluid retention and are not to be used in patients with liver disease. However, there is a lack of data demonstrating that any of these three drugs is superior to the other two medications. Thus, the patients pulmonary arterial hypertension can be treated with either of the Health Insurers formulary medications, Tracleer or Letairis with equivalent efficacy. Therefore, the Opsumit provided from 4/22/15 forward was not and is not medically necessary for treatment of this patients pulmonary arterial hypertension.