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

Summary Reviewer 3

A 30-year-old male enrollee has requested reimbursement for immunoglobulin heavy chain locus gene rearrangement and immunoglobulin kappa light chain locus gene arrangement testing performed on 2/14/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. This patient did not have a diagnosis, and an underlying lymphoproliferative disorder was suspected. T-cell lymphomas are a subtype of non-Hodgkin lymphomas that can present with leukopenia, pruritus, skin infiltration, organomegaly, eosinophilia, thrombocytopenia, and anemia. T-cell receptor rearrangement is part of routine testing in such cases. The presence of TCR clonality raises the suspicion of lymphoma but a negative result does not rule it out. Thus, the order of T-cell gene rearrangement was indicated to rule out a clonal T-cell receptor disorder. Similarly, most non-Hodgkin lymphomas are derived from B-cells where immunoglobulin heavy and light chain rearrangement studies are standard diagnostic procedures. The current National Comprehensive Cancer Network guidelines for lymphomas, both B-cell and T-cell, state that gene rearrangement studies are part of the diagnostic algorithm. Gene rearrangement studies are the standard of care. All gene studies ordered in this case were part of standard medical care. Thus, immunoglobulin heavy chain locus gene rearrangement and immunoglobulin kappa light chain locus gene arrangement testing performed on 2/14/19 were likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 33-year-old female enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) test and Factor V Leiden performed on 5/17/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of deep vein thrombosis and pulmonary embolism. The physician reviewer found that a prior personal history of deep vein thrombosis/pulmonary embolism, especially in the setting of oral contraceptive use or pregnancy, is a significant risk factor for thrombosis during pregnancy. Since no records were available regarding prior laboratory work-up for inherited thrombophilias, Factor V Leiden testing was medically appropriate. However, the medical evidence does not support MTHFR testing in this setting since MTHFR mutations have not been associated with venous thromboembolism either in pregnant or non-pregnant patients. Therefore, Factor V Leiden testing performed on 5/17/18 was likely to have been of greater benefit than other methods of evaluating this patient. However, the superior efficacy of MTHFR has not been established. Based upon the information set forth above, a portion of the services 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 partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 33-year-old female enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) test and Factor V Leiden performed on 5/17/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of deep vein thrombosis and pulmonary embolism. The physician reviewer found that women who screen positive for the Factor V Leiden deficiency are at greater risk for an adverse thrombotic event especially when faced with certain clinical situations, such as surgery, immobilization, hormone replacement, birth control pills and pregnancy. The medical management of pregnancy is very different if a patient is found to be high-risk secondary to being positive for a thrombophilia study. This patient has a personal history of deep vein thrombosis/pulmonary embolism while on birth control pills, and is a high-risk patient. Thus, Factor V Leiden testing was appropriate. However, there is a lack of support for MTHFR testing. Although some studies suggest patients are at increased risk during pregnancy, other studies have not. The risk seems to be mediated through hyperhomocysteine levels. Given the effects of folic acid decreasing these levels, it is only recommended to supplement patients with B6, B12, and folic acid. This has been done with this patient. In sum, Factor V Leiden performed on 5/17/18 was likely to have been of greater benefit than other methods of evaluating this patient. However, the superior effectiveness of MTHFR has not been established. Based upon the information set forth above, a portion of the services 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 partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 33-year-old female enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) test and Factor V Leiden performed on 5/17/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of deep vein thrombosis and pulmonary embolism. The physician reviewer found that the submitted documentation supports a portion of the services at issue. Factor V Leiden screening is recommended for women with a past history of deep vein thrombosis/pulmonary embolism. However, the clinically usefulness of the MTHFR mutations are unknown, and routine screening is not recommended. Given the lack of association between either heterozygosity or homozygosity for the MTHFR C677T polymorphism and negative pregnancy outcomes, MTHFR testing is not recommended. Thus, Factor V Leiden performed on 5/17/18 was likely to have been of greater benefit than other methods of evaluating this patient. However, the superior effectiveness of MTHFR testing has not been demonstrated. Based upon the information set forth above, a portion of the services 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 partially overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 64-year-old male enrollee has requested reimbursement for magnetic resonance imaging of the pelvis performed on 3/1/17. The Health Insurer has denied this request indicating that the service at issue was not medically necessary for evaluation of the enrollee who has a history of hemorrhoidectomy and elevated prostate specific antigen (PSA). The physician reviewer found that the medical literature supports the medical necessity of the service at issue in this clinical setting. In this patient, the PSA levels are borderline, and more importance is being paid to the trend in values over the last several tests.  The question is whether to proceed with a biopsy, and the provider is asking for an MRI to assist in that decision. MRI has become a common imaging procedure to better evaluate the prostate. A well-known prostate researcher, Siddiqui has written, targeted MRI/ultrasound fusion biopsy, compared with standard extended-sextant ultrasound-guided biopsy, was associated with increased detection of high-risk prostate cancer and decreased detection of low-risk prostate cancer, (Siddiqui, p. 390). Current National Comprehensive Cancer Network (NCCN) guidelines state that MRI is not recommended routinely prior to initial prostate biopsy, but emerging data suggest that, in men undergoing initial biopsy, targeting using MRI/ultrasound fusion may increase the detection of clinically significant, higher-risk (Gleason grade > or equal to 4 + 3=7) disease while lowering the detection of lower-risk (Gleason sum 6 or lower-volume Gleason 3 + 4=7) disease. Consequently, for this patient, if the patient does not have suspicious findings on multiparametric MRI, there is only a 3% chance of detecting a clinically significant cancer, whereas if the MRI has suspicious findings, then a biopsy could be warranted. Based on the medical research, multiparametric MRI was useful for this patient, and may have helped him avoid life-altering complications that could occur with unnecessary surgery. MRI of the pelvis performed on 3/1/17 was medically necessary for the evaluation of this patients medical condition. Therefore, for the reasons stated above, the service at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 58-year-old male enrollee has requested authorization and coverage for posterior cervical disc fusion C2-T2 and two bed days. 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 records document a history of severe neck pain associated with radiculopathy as well as myelopathy and a probable pseudarthrosis at C7-T1 and cervicothoracic kyphosis. There is a history of prior anterior and posterior cervical fusion. The provider is requesting revision surgery from C2 to T2 posteriorly. Loosening of the pedicle screws at C7 and intra-facet placement of the C3 screws are documented. Per the literature, instability of the cervicothoracic junction is fairly common after a long cervical fusion. In the study by Truumees and colleagues, a total of 177 adult spine patients undergoing three or more levels of posterior cervical fusions for degenerative disease were included. According to this study, extension of the posterior cervical fusion into the thoracic spine leads to a lower pseudarthrosis rate. Furthermore, correction of the cervicothoracic kyphosis will also be necessary to relieve pain. Additionally, the proximal extension of the posterior construct to C2 is also necessary for stability in this long construct and for revision of the proximal intra-articular pedicle screws described by the provider. Therefore, posterior cervical disc fusion C2-T2 and two bed days are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 26-year-old female enrollee has requested authorization and coverage for breast reconstruction. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees bilateral tuberous breast deformity. The physician reviewer found the submitted documentation establishes the medical necessity of the requested procedure. The patient presents with well-documented tuberous breast deformity and she has had previous reconstructive surgery with implants. Essentially, this has failed and the patients current condition is consistent with continued lack of breast development and findings consistent with significant breast deformity.  Based on the documentation and review of the photographs, this is not a normal variant. Significant breast deformity can exist with tuberous breasts (DeLuca-Pytell, et al; Mandrekas, et al). According to DeLuca-Pytell and colleagues, Tuberous breast deformity is characterized by an aberration of breast shape. Characteristics include a constricted breast base, hypoplastic breast tissue, herniated nipple-areola complex, deficient skin envelope inferiorly, and elevated inframammary fold. This classification is consistent with the presentation of this patient. Based on the overall clinical picture presented supported by photographs, and the fact that the patient has failed previous breast reconstruction and continues to have findings of a bilateral tuberous breast deformity, the requested procedure is medically necessary. This patient has abnormal breast development and surgical intervention is medically necessary to approximate a more normal condition. For the reasons provided, the requested procedure 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 


A 28-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation and autologous cultured chondrocytes implant for left knee. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees left knee pain.  The physician reviewer found that treatment of osteochondral defects with autologous chondrocyte implantation has been proposed for treatment of this patients cartilage defects in the knee. The patients provider has submitted additional information in support of the patients request for authorization for the procedure. Based upon review of the additional information, the requested procedure is medically reasonable and appropriate in this case. While the evidence regarding autologous chondrocyte is mixed, as noted by the treating provider there is documentation of positive outcomes cited in literature. As such, there is sufficient evidence in the available data to support the efficacy of autologous chondrocyte implantation and autologous cultured chondrocytes implant in this clinical setting. Therefore, the requested procedure is medically necessary for treatment of the patients medical condition. Based on the foregoing discussion, the requested procedure is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 65-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 6/13/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who has a history of breast cancer. The physician reviewer found that breast tomosynthesis was approved for clinical use by the U.S. Food and Drug Administration in 2011. Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  The use of this technique often allows the reader to separate dense glandular elements from underlying architectural distortion and mass, which in turn improves diagnostic accuracy, reduces callbacks and reduces negative biopsies. The medical evidence supports the service at issue in this clinical setting. Therefore, breast tomosynthesis performed on 6/13/17 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 2

A 65-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 6/13/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who has a history of breast cancer. The physician reviewer found that digital mammography screening has been proven to decrease mortality related to breast cancer. Standard or two-dimensional mammography does have significant limitations, namely obscuration of cancers within areas of overlapping or dense tissue, as well as false positive recalls due to overlapping breast tissue, which must be confirmed with additional imaging. Digital breast tomosynthesis addresses both of these issues. The addition of breast tomosynthesis decreases the false positive recall rate by 15%. It does this by allowing the radiologist to scan through slices of breast tissue rather than seeing the breast tissue superimposed on itself. In sum, breast tomosynthesis performed on 6/13/17 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 65-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 6/13/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who has a history of breast cancer. 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 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. Another advantage of tomosynthesis is better delineation and characterization of breast masses. In very recent years, there have been several studies that have supported the use of breast tomosynthesis as a more accurate study than routine screening mammography. Skaane and colleagues noted 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. Friedewald and colleagues noted that the addition of tomosynthesis to digital mammography was associated with a decrease in recall rate and an increase in cancer detection rate. In this patients case, given her recent history of breast cancer, performing her surveillance with breast tomosynthesis was appropriate. Thus, breast tomosynthesis performed on 6/13/17 was likely to have been superior over other available modalities for 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer

The patient is a three-year-old female who was transported by air ambulance from Childrens Hospital in Centennial, Colorado (CHCC) to Childrens Hospital in Millard, Nebraska (CHMC) on 6/30/15. The patient was born with a congenital diaphragmatic hernia on 1/29/15. She was intubated at birth. The patient underwent several surgeries. She remained with severe pulmonary hypertension. Multiple attempts to wean the child from the ventilator failed. It was determined that the patient no longer required the services of a level IV neonatal intensive care unit (NICU). The decision was made to transfer the patient to a level III NICU in Nebraska to be closer to her home. The ambulance was scheduled in advance on 6/29/15. The transport was initiated on 6/30/15, and no adverse events occurred during transport. The Health Insurer has denied reimbursement for air ambulance services provided on 6/30/15. Per the Health Insurer, the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination.  Air ambulance services are considered medically necessary under certain circumstances. These circumstances include: the patients condition is such that any other means of transport would be medically contraindicated, the patients condition is such that the time necessary for transport by land poses a threat to the patients health, and the patient is transported to the nearest hospital with appropriate facilities for treatment. All of these criteria must be met in order for air ambulance transport to be medically necessary. In this case, the patient was being transferred from a level IV NICU to a level III NICU, a lower level of care. This transfer was planned in advance, not completed emergently. The patient was transferred to another state in order to be closer to home. There are other NICU facilities closer to CHCC than CHMC. All told, air ambulance services provided on 6/30/15 were not medically necessary for the treatment of this patient. 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 56-year-old female enrollee has requested reimbursement for a blood test performed on 11/24/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The choice of test used to diagnose Helicobacter pylori depends on whether a patient requires an upper endoscopy for evaluation of symptoms or surveillance. Endoscopy is not indicated solely for the purpose of establishing Helicobacter pylori status. In patients who do not require endoscopic evaluation, initial diagnosis of Helicobacter pylori should be made with a test for active infection (stool antigen or urea breath test). The urea breath test and stool antigen assay both have high sensitivity and specificity for identifying active Helicobacter pylori infection. Serology has low sensitivity and specificity for Helicobacter pylori and cannot differentiate between active and past infection. Therefore, the blood test performed on 11/24/18 was not likely to have been more effective than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 56-year-old female enrollee has requested reimbursement for a blood test performed on 11/24/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the records noted that the patient previously tested positive for Helicobacter pylori. However, the modality of testing was not specified. Consistent with standard of care, Braden noted 13C urea breath test or the stool antigen test can be used for non-invasive screening for Helicobacter pylori in a test and treat strategy in younger patients presenting with dyspepsia without alarm symptoms without the need for endoscopic prelude to therapy or re-treatment. Serologic testing, as in this patients case, was not recommended as the study of choice or standard of care. The immunoglobulin G (IgG) antibody assayed in this case offers little assistance in distinguishing between active disease and previous exposure. Further, antibodies to Helicobacter pylori can remain elevated for a long time even after treatment, potentially increasing the number of false-positive results. In this patients case, the records do not specify whether she received treatment upon Helicobacter pylori detection in Taiwan, or whether it was her desire to be retested to assess efficacy of past eradication efforts. Serologic testing for re-documentation of a previously positive Helicobacter pylori status was not likely to have been more beneficial in achieving positive outcome than standard testing with detection of active infection with stool antigen or urea breath assays. In sum, the blood test performed on 11/24/18 was not likely to have been of greater benefit than other methods of evaluating this patient.