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

Summary Reviewer 3

A 44-year-old male has requested authorization and coverage for total disc arthroplasty at the levels of L4-L5 and L5-S1. 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 FDA approval for the ProDisc-L total disc replacement states that approval expands the indications for use of the ProDisc-L to include treatment of up to two consecutive lumbar spinal sections (levels) from L3-S1. Zigler and colleagues concluded that patients undergoing both ProDisc-L total disc replacement and circumferential arthrodesis for the treatment of single-level degenerative disc disease maintained significant improvement during the five-year follow-up. The total disc replacement group had significantly better improvement on some scales. The authors concluded, aAlthough total disc replacement patients avoid the stiffness of fusion and are more satisfied than fusion patients, both fusion and total disc replacement are reasonable surgical options in this specific patient population.a Siepe and colleagues concluded, aThe subjective outcome evaluation indicates that total disc replacement is a viable treatment option even in advanced stages of degenerative disc disease in the absence of other contraindications, in particular facet joint arthropathies.a This patient presents with persistent and ongoing low back pain. He continues to have severe low back pain impacting his function. Range of motion is restricted and painful. The submitted documentation demonstrates subjective and objective deficits that are corroborated by imaging studies. Trial and failure of conservative treatment modalities have been documented. Therefore, total disc arthroplasty at the levels of L4-L5 and L5-S1 is likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 49-year-old female enrollee has requested authorization and coverage for Sovaldi and Daklinza.  The Health Insurer has denied this request indicating that the requested medications are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. However, no reason is provided for ribavirin ineligibility.  The guidelines only recommend Sovaldi and Daklinza therapy for treatment-naive genotype 2 patients who are ribavirin-ineligible.  Otherwise, guidelines recommend Sovaldi and ribavirin as first-line therapy instead.  For these reasons, the requested treatment with Sovaldi and Daklinza is not medically indicated for the treatment of this patient.  Therefore, the requested medications are 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

The parent of a 13-year-old female enrollee has requested reimbursement for transcutaneous electrical modulation pain processing provided from 12/03/18 through 5/14/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that complex regional pain syndrome is a debilitating chronic pain syndrome that poses incredible challenges to the patient. Clear pathophysiology of complex regional pain syndrome is still being understood, and treatment options are primarily based on clinical experience and individual patients response to therapies, as strong evidence-based treatment options are lacking. A recent review by Shim and colleagues highlighted early use of physical/occupational therapy with neuropathic medications. Neuromodulation is also an option with evidence for appropriate candidates. 

Scrambler Therapy is an electro-analgesia therapy with the intent to re-organize maladaptive signaling pathways that exist in chronic pain. It is used for the treatment of cancer pain, chronic neuropathic pain and refractory pain conditions. A review by Majithia and colleagues concluded that findings from available studies support Scrambler Therapy as a beneficial treatment option for patients with refractory pain syndromes. An observational study by Ricci and colleagues consisting of 219 patients with chronic pain treated with Scrambler Therapy showed a statistically significant impact of Scrambler Therapy. In this case, the patient is experiencing exacerbations of pain from complex regional pain syndrome that has been refractory to other treatments, and she has benefited from Scrambler Therapy in the past. Therefore, transcutaneous electrical modulation pain processing provided from 12/03/18 through 5/14/19 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

The parent of a 13-year-old female enrollee has requested reimbursement for transcutaneous electrical modulation pain processing provided from 12/03/18 through 5/14/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that Scrambler Therapy has been shown to be beneficial for complex regional pain syndrome. In this patients case, the records document complex regional pain syndrome. She has been treated with physical therapy, epidurals, and other conservative treatment options and pain management techniques, without significant pain relief. Prior treatment with Scrambler Therapy in 2018 was reportedly beneficial. There are clinical trials and journal articles that show statistically significant benefit utilizing these modalities for complex regional pain syndrome. There is sufficient support for the services at issue in this clinical setting. All told, transcutaneous electrical modulation pain processing provided from 12/03/18 through 5/14/19 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

The parent of a 13-year-old female enrollee has requested reimbursement for transcutaneous electrical modulation pain processing provided from 12/03/18 through 5/14/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that Nayback-Beebe and colleagues evaluating the efficacy of Scrambler Therapy on chronic pain. The authors found, The groups showed no statistically significant differences in pain scores, medication use, or mental or physical health-related quality of life with active versus sham treatment. However, both produced clinically meaningful reductions in pain and improvements in physical health-related quality post-treatment that was sustained at 1-month follow-up. The authors concluded, Scrambler Therapy is no better than sham treatment in decreasing pain. Yet, patient perceptions of treatment effectiveness are equally important in chronic pain treatment. Goh and colleagues performed a systematic review on current standards of care for complex regional pain syndrome. The authors described several of the current standard treatments, including physical therapy, psychological treatments, pharmacological therapies, as well as interventional treatments, including sympathetic blockade and surgical approaches. There is no mention of Scrambler Therapy as an accepted treatment for complex regional pain syndrome. 

In this case, the patient has complex regional pain syndrome that has not responded to physical therapy or epidural steroid injections. The current evidence supporting the Scrambler Therapy for chronic pain is very limited, with a lack of large randomized control studies to demonstrate clear benefit. Furthermore, there is a lack of studies in the published peer-reviewed literature evaluating the benefits of this therapy specifically for complex regional pain syndrome and showing superiority to standard of care. Thus, transcutaneous electrical modulation pain processing provided from 12/03/18 through 5/14/19 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 55-year-old male enrollee has requested authorization and coverage for heart surgery (93580, percutaneous transcatheter closure of heart defect). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees patent foramen ovale. The physician reviewer found that this patient had a stroke at a young age without documented other risk factors. He is in normal sinus rhythm. A transesophageal echocardiography showed evidence of a patent foramen ovale. Anticoagulation therapy would need to be lifelong, with a significant bleeding risk. The current medical evidence supports closure of a shunting patent foramen ovale, especially in younger patients with cryptogenic stroke in whom all other stroke etiologies have been effectively ruled out. Given the documented history of stroke, the lack of other identifiable causes of stroke, and otherwise the need for long-term anti-coagulation in this younger patient, the requested heart surgery (93580, percutaneous transcatheter closure of heart defect) 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.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 55-year-old male enrollee has requested authorization and coverage for heart surgery (93580, percutaneous transcatheter closure of heart defect). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees patent foramen ovale. The physician reviewer found that the submitted records fails to demonstrate the superior efficacy of the requested services in this clinical setting. In this circumstance, while there is increasing evidence to suggest that patent foramen ovale device closure may more effective than medical therapy alone for select patients age 60 years or younger with a cryptogenic non-lacunar ischemic stroke who have a patent foramen ovale, the patients most likely to benefit are those with large right-to-left interatrial shunting and/or an associated atrial septal aneurysm, neither of which is documented in this patient. Based on the documentation, medical management with aspirin is most appropriate in this case. In sum, heart surgery (93580, percutaneous transcatheter closure of heart defect) is not likely to be more efficacious than other treatment options. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 55-year-old male enrollee has requested authorization and coverage for heart surgery (93580, percutaneous transcatheter closure of heart defect). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees patent foramen ovale. The physician reviewer found that the use of device closure of patent foramen ovale for prevention of cryptogenic stroke has been the subject of much research study over a long period. Current guidelines from 2014 do not recommend patent foramen ovale closure. New studies suggest that there may be a change in guidelines, but a change has not yet taken place. Of note is that some studies emphasize high-risk patent foramen ovale which involves a larger shunt, size over 2 mm, atrial septal aneurysm or mobile septal motion, none of which was documented in this patients case. Thus, heart surgery (93580, percutaneous transcatheter closure of heart defect) is not likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 56-year-old female enrollee has requested authorization and coverage for spinal cord stimulator. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees chronic low back pain. The physician reviewer found that the requested spinal cord stimulator is not medically necessary in this clinical setting. The records provided do not have spine pain targeted in the dermatomal distribution that may be treated with spinal cord stimulation. Additionally, there is no psychological evaluation. Finally, the records do not indicate that this patient has tried and failed all forms of treatment including surgery. There is not a surgical consultation documenting that the patient is a not surgical candidate. Per Block and colleagues, Back pain is experienced by up to of 85% of the United States population. Most often it resolves with minimal to no medical treatment. For those whose pain endures, worsens, or becomes protracted, conservative care is typically first attempted. Individuals who continue to experience significant back pain are often considered for surgical procedures, the results of which are not uniformly positive. Current peer reviewed, medical literature demonstrates the spinal cord stimulator to be indicated for severe, highly debilitating conditions for which this patient has not been shown to have. 
Based on the medical documentation presented for review, the patient does not have severe paralysis or complex regional pain syndrome for which this treatment modality is better suited. Based on current peer reviewed medical literature and in consideration of the submitted clinical records, the spinal cord stimulator trial is not medically necessary or the standard of care. The standard of care for treatment of the patients condition includes anticonvulsant, antidepressants, and opioid medications targeting neuropathic pain. As such, the spinal cord stimulator is not medically necessary for the treatment of this patients medical condition. Therefore, for the reasons stated above, the requested services are 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 2

A 25-year-old male enrollee has requested reimbursement for quantitative EEG (brain mapping) performed from 7/02/20 through 8/25/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeAaas medical condition. The physician reviewer found that the patient has history of major depressive disorder with suicidal ideations. He has been previously hospitalized for psychiatric care for the same. The patient has already received traditional care for this diagnosis. There is evidence that quantitative EEG can have findings which can be used a biomarker for suicidality. EEG activity in theta band has clinical potential as a biomarker for preventing suicide. Furthermore, high-gamma rhythm has the potential to be used as a biomarker for screening suicidality. The use of quantitative EEG findings can be used to treat patients with neurofeedback. Therefore, quantitative EEG (brain mapping) performed from 7/02/20 through 8/25/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 25-year-old male enrollee has requested reimbursement for quantitative EEG (brain mapping) performed from 7/02/20 through 8/25/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeAaas medical condition. The physician reviewer found that standard of care for major depressive disorder involves treatment with different classes of antidepressants, such as selective serotonin reuptake inhibitors, serotoninAaanorepinephrine reuptake inhibitors, bupropion, mirtazapine or newer generation antidepressants. After a patient fails antidepressant trials from multiple classes, the standard of care is to then add an adjunctive medication, such as aripiprazole, quetiapine, risperidone, or lithium. This patient tried only one antidepressant. Psychotherapy (specifically cognitive behavioral therapy) is also highly recommended as a first-line treatment for depression as well as anxiety disorder, as well as the combination of pharmacotherapy and psychotherapy. There is no documentation provided that the patient failed psychotherapy. Given that there is no documentation (Patient Health Questionnaire 9 other other rating scores) of the patientAaas improvement before and after neurofeedback treatment, and this treatment has very little evidence showing benefit in this specific condition (major depression), standard therapy (adjunctive medications, CBT, other psychotherapy, ECT) should have been tried. Therefore, quantitative EEG (brain mapping) performed from 7/02/20 through 8/25/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


The parent of a 12-year-old male enrollee has requested reimbursement and prospective authorization and coverage for intravenous immune globulin therapy. The Health Insurer has denied this request indicating that the services at issue were and are investigational for the treatment of the enrollees medical condition. The physician reviewer found IVIG treatment is clinically supported in this patients case. In the treatment of autoimmune encephalitis, studies support steroids, IVIG and plasma exchange as first-line treatment and second-line treatment with rituximab and cyclophosphamide. In many cases, this is followed by steroid-sparing agents in the long-term. Autoimmune encephalitis is a rare condition and randomized controlled therapeutic trial data are limited for autoimmune encephalopathy, due to its low prevalence and due to the heterogeneous group of disorders that fall under this heading, which require very different therapeutic approaches. Fortunately, autoimmune encephalopathy typically responds quickly and completely to steroid therapy alone; however, this patient has a steroid allergy. For patients who are intolerant of steroids, weekly IVIG is found to be effective. For these reasons, the services at issue were and are likely to be more beneficial for treatment of the patients medical condition than any standard therapy.Based upon the information set forth above, the services at issue were and 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.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


The parent of a 12-year-old male enrollee has requested reimbursement and prospective authorization and coverage for intravenous immune globulin therapy. The Health Insurer has denied this request indicating that the services at issue were and are investigational for the treatment of the enrollees medical condition.The physician reviewer found the medical literature supports the use of IVIG in patients with autoimmune encephalitis. In this patients case, he had pre-existing autoimmune disease in the form of Hashimotos thyroiditis, and then developed acute symptoms associated with autoimmune encephalitis. He has an allergy to prednisone, and has thus far responded well to sequential administration of IVIG. His specialists have recommended a prolonged course of IVIG to prevent recurrence of this complication of his autoimmune disease. Autoimmune encephalitis, or antibody-mediated encephalitis, affects children and adults, and is emerging as a more common cause of encephalopathy in these populations. Current treatment strategies involve removal of existing antibodies, in the form of intravenous immunoglobulins and plasmapheresis, as well as immunosuppression to decrease production of antibodies. The first-line therapy then includes IVIG, parenteral steroids, and plasmapheresis, with some potential additional benefit from second-line immunosuppressant therapies. For all these reasons, the services at issue were and are likely to be more beneficial for treatment of this patients autoimmune encephalitis than any available standard modality.For the reasons set forth above, the services at issue were and 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.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


The parent of a 12-year-old male enrollee has requested reimbursement and prospective authorization and coverage for intravenous immune globulin therapy. The Health Insurer has denied this request indicating that the services at issue were and are investigational for the treatment of the enrollees medical condition. The physician reviewer found in this clinical setting, there is support for IVIG in treatment of this patients medical condition. The patient has been treated with IVIG with associated improvement in symptoms. A medical review of IVIG and encephalitis revealed use of immunoglobulins and plasmapheresis as alternatives to steroids for Hashimotos encephalopathy in a case series (Yu et al). IVIG has seen associated with improvement in children with acute encephalitis syndrome complicated by myocarditis (Bhatt et al). In a recently published review of autoimmune encephalitis, it was stated that the repertoire of autoimmune encephalitis in children is different from that of adults. The younger the child the more difficult it is to recognize specific autoimmune encephalitis syndrome, which suggests that guidelines for pediatric autoimmune encephalitis will be more dependent on antibody and other ancillary tests than the syndrome-based guidelines in this Position Paper (Graus et al). In a study of acute immune-mediated and infectious encephalitis in 28 children, immune-modulating therapies were given to 28 patients. The authors wrote that although evidence is limited to retrospective series and case reports, the best available data suggests that early treatment with intravenous immunoglobulin or plasmapheresis, or both, followed by long-term immunosuppression is associated with better outcomes.  A study regarding off-label medication use in 677 children admitted to an academic pediatric critical care unit published that FDA-prescribing guidelines were available in less than 35% of the commonly prescribed medications (Hsu and Brazelton). Given the above-referenced medical literature, IVIG was and is likely to be more efficacious for treatment of the patients autoimmune encephalitis symptoms than any available standard therapy. Therefore, the services at issue were and 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.