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

Summary Reviewer 2

A 55-year-old female enrollee has requested reimbursement for CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy provided from 2/10/15 through 2/13/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found the current medical evidence does not support the services at issue in this clinical setting.  The patient is being treated with subcutaneous immunotherapy for mast cell disease, food allergy and multiple chemical sensitivities.  Per the literature, subcutaneous immunotherapy using preparations of aeroallergens may be indicated in specific clinical settings.  Studies have demonstrated that patients with both asthma and allergic rhinitis derive particular benefit.  In this case, the patient does not have a diagnosis that is appropriate for subcutaneous immunotherapy.  Therefore, the superior efficacy of the services at issue has not been established.  Based upon the information set forth above, the services at issue were 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 female enrollee has requested reimbursement for CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy provided from 2/10/15 through 2/13/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found in this case, the patient has a history of mast cell disorder, multiple chemical sensitivities and food allergy.  Allergen immunotherapy is a well-standardized treatment options.  The current national guidelines indicate that allergen immunotherapy may be efficacious in the treatment of allergic rhinitis, allergic conjunctivitis, allergic asthma, and stinging insect hypersensitivity.  In this case, there is no evidence of the above diagnoses.  As such, CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy provided from 2/10/15 through 2/13/15 was not likely to have been more efficacious than other treatment options.  Based upon the information set forth above, the services at issue were 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 year-old female enrollee has requested reimbursement for collagen crosslink testing provided on 4/17/19. 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 Osteoporosis is a condition of thinning of the bones that leads to an increased risk of fracture.  It  is defined by the World Health Organization (WHO) as a bone mineral density of 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults), as measured by dual-energy x-ray absorptiometry (DEXA). Bone mineral density assessment via DEXA is still the criterion standard for evaluation and diagnosis of osteoporosis. However, because changes in bone mass and density in response to antiresorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover may be a useful adjunct in monitoring of osteoporotic patients treated with antiresorptive agents. Medical evidence suggests that biochemical markers could be useful in making therapeutic decisions because, in general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine. There is sufficient support for the services at issue in this clinical setting. Therefore, collagen crosslink testing provided on 4/17/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A year-old female enrollee has requested reimbursement for collagen crosslink testing provided on 4/17/19. 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. Bone turnover marker assays measure collagen breakdown products released from osteoclasts and osteoblasts during the process of bone resorption and formation. Bone turnover markers are useful for monitoring osteoporosis treatment. This patient was on bisphosphonate therapy for six years and is currently on a drug holiday. Her provider is monitoring her bone turnover markers so that she can decide the timing of restarting antiresorptive therapy, if needed in the future. The services at issue were medically appropriate in this clinical setting. In sum, collagen crosslink testing provided on 4/17/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A year-old female enrollee has requested reimbursement for collagen crosslink testing provided on 4/17/19. 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 the use of bone turnover markers is standard practice among endocrinologists and other specialists in osteoporosis. It is used as a guide to monitor compliance and efficacy of treatment. It also helps to identify non-responders that require additional work-up for other causes of osteoporosis. In this case, the patients provider planned to use the information from this test result to determine whether the patient may resume therapy for osteoporosis and subsequently to monitor therapy. Naylor and colleagues noted that measurement of bone turnover markers after withdrawal of bisphosphonates is potentially useful to evaluate patients that are taking a pause from treatment. Thus, collagen crosslink testing provided on 4/17/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 62-year-old female enrollee has requested reimbursement for acute hospital admission to telemetry level of care from 9/24/18 through 9/25/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who had a history of chest pain. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The records document some coronary risk, chest pain concerning for possible ischemia, a normal cardiovascular physical examination, an unchanged electrocardiogram and an initial negative evaluation in the emergency department. In this circumstance, it would have been reasonable to anticipate a hospital length of stay to require less than 48 hours or less than two midnights, and it would have been safe to manage the patient at an observational level of care as opposed to an inpatient admission. There was no documented hemodynamic instability or objective evidence of coronary ischemia or other acute medical condition to warrant an inpatient admission. Thus, acute hospital admission to telemetry level of care from 9/24/18 through 9/25/18 was 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 46-year-old male enrollee has requested authorization and coverage for Vemlidy 25 mg daily. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects, such as osteopenia and renal disease. As hepatitis B is chronic in this case, with the possibility of increased disease activity when treatment is discontinued, the request for 12 months of treatment is appropriate. Therefore, Vemlidy 25 mg daily is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 20-year-old female who has a history of alopecia totalis. The patient has requested authorization and coverage for Xeljanz (tofacitinib citrate tablet 5 mg). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. Standard of care for the treatment of alopecia totalis/universalis includes systemic steroids, methotrexate, cyclosporine, Janus kinase inhibition, and contact sensitization with diphenylcylopropenone or squaric acid. Few treatment methods have been evaluated by randomized controlled trials to determine the most efficacious modalities to treat alopecia areata. Therefore, it is challenging for clinicians to guide patients regarding the best therapeutic options. Janus kinase inhibitors, like Xeljanz, do show excellent promise and some great results in treating extensive alopecia. This patient has already had a trial of Xeljanz, is tolerating it well, and is achieving a reduction in her SALT score. Janus kinase inhibition has been found to be well tolerated and effective in the treatment of alopecia. Therefore, Xeljanz (tofacitinib citrate tablet 5 mg) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A year-old male enrollee has requested reimbursement for inpatient hospital stay at telemetry level of care from 8/06/18 through 8/09/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that at the time of presentation to the emergency department, the patient reported leg pain with swelling.  He did not complain of chest pain or difficulty breathing, but he was tachycardic and febrile with increased respiratory rate. The laboratory studies were significant for an elevated troponin. Although there was no obvious cardiac ischemia on echocardiogram, the cardiac enzymes were abnormal and the patient was tachycardic. Admission to an acute inpatient level of care with telemetry was medically reasonable from 8/03/18 through 8/05/18. The patient stabilized medically with treatment, including antibiotics and intravenous fluids. There was no evidence of significant electrolyte abnormalities, cardiac ischemia or dysrhythmia as of 8/05/18. Therefore, inpatient hospital stay at telemetry level of care from 8/03/18 through 8/05/18 was medically necessary for the treatment of this patient. The medical records fail to demonstrate the medical necessity of inpatient hospital stay at telemetry level of care from 8/06/18 through 8/09/18.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 58-year-old male with a history Wegeneras granulomatosis. The patient has requested authorization and coverage for Hizentra (immune globulin (human) subcutaneous solution preferred syringe 4 gm/20 ml). The physician reviewer found that the patientas clinical history, presentation and laboratory findings, including low level of immunoglobulin G level and poor antibody response to pneumococcal antibody, support the use of immunoglobulin replacement therapy. The current medical evidence supports subcutaneous immunoglobulin therapy in this clinical setting.  Therefore, Hizentra (immune globulin (human) subcutaneous solution preferred syringe 4 gm/20 ml) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 58-year-old male with psoriasis. He has requested authorization and coverage for Otezla 30 mg. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that based on the psoriasis treatment guidelines put forth by the American Academy of Dermatology- National Psoriasis Foundation, patients who have psoriasis affecting between 3 to 10% (defined as moderate) and greater than 10% (defined as severe) of their body surface area are candidates for phototherapy and systemic medical therapy. There are no step therapy guidelines recommended in this context, and the choice of therapy should be made at the discretion of the treating provider, with attention paid to patient comorbidities. Otezla is U.S. Food and Drug Administration (FDA) approved and indicated for treatment of moderate-to-severe psoriasis and has Level A evidence to support its efficacy. Given that the patient has documented evidence of moderate-to-severe disease combined with the fact that there is documented evidence of effectiveness with starter pack samples, it is medically appropriate to continue this therapy. Therefore, Otezla 30 mg is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 57-year-old male has requested authorization and coverage for cervical artificial disc replacement.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that he submitted documentation fails to demonstrate the superior efficacy of the requested services.  Evidence-based medical guidelines and peer-reviewed literature do not support the use of an artificial disc replacement adjacent to a prior (multilevel) anterior cervical discectomy and fusion.  This patient presents with intractable discogenic pain and bilateral C4 motor radiculopathy.  He is status post C4-C7 fusion in 2011, with onset of adjacent segment disease at C3-4 in 2012.  Artificial disc replacement at the adjacent level has been requested for functional motion preservation.  However, the use of an artificial disc replacement adjacent to prior cervical fusion is not supported by current literature.  There is a lack of long-term, large volume studies to support the requested services.  Therefore, the requested cervical artificial disc replacement 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 2


A 57-year-old male has requested authorization and coverage for cervical artificial disc replacement.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested services in this patients case.  A review of the current literature pertaining to artificial disc replacement adjacent to a fused level indicates results superior to anterior cervical discectomy and fusion.  In particular, due to preservation of the motion, adjacent segment disease may be minimized.  The current medical evidence supports the recommended cervical artificial disc replacement in this clinical setting.  Therefore, the requested cervical artificial disc replacement is likely to be more effective than other treatment alternatives.  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 3


A 57-year-old male has requested authorization and coverage for cervical artificial disc replacement.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  This patient has symptoms noted since May 2012 which suggest multilevel nerve root changes which would not necessarily be addressed through a C3-4 discectomy and artificial disc replacement.  Complications specific to total disc replacement include implant failure, wear, bone implant failures, iatrogenic deformity, segmental kyphosis, failed kinematics, neurological injury and infection.  It is known that the metal to methyl methacrylate bearing surface will be exposed to the wear mechanisms of abrasion, adhesion, fatigue and third body wear.  A continuing particulate load of these particles will occur.  It is known that there is a universal giant cell reaction and chronic inflammation in response to wear debris.  A justification and rationale for total disc arthroplasty is the prevention of adjacent segment disorder through preservation of motion.  However, it remains controversial whether or not motion at the replaced intervertebral disc will be maintained over time, and there is evidence that there is a gradual loss of motion by reason of a number of factors.  One of the most important of these factors is myositis ossificans, fibrous tissue and bone or an inflammatory response to wear and to the trauma of surgery, which involves the formation of both.  Thus, the requested cervical artificial disc replacement 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 66-year-old man with lumbar stenosis. The patient has requested authorization and coverage for lumbar spine surgery (laminectomy, facetectomy and foraminotomy, single vertebral segment). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. The patient has severe lumbar stenosis with neurogenic claudication. Decompression is well supported by the referenced literature to reduce pain and increase function. The current medical evidence supports the requested services in this patientas case. Therefore, the requested lumbar spine surgery (laminectomy, facetectomy and foraminotomy, single vertebral segment) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 19-year-old male enrollee has requested reimbursement for residential treatment services provided from 11/13/14 through 12/22/14.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found in this patients case, despite pharmacotherapy with antipsychotic and antianxiety agents, the patient was irritable and anxious with poor eye contact, limited insight and a blunted affect.  He endorsed somatic delusions of having toxins in his body, which was likely an extension of his assertion that he had an eating disorder.  He also complained of chronic headaches and gastrointestinal distress.  During the disputed course of treatment, the patient demonstrated signs of clinical improvement and was engaged in active treatment.  Regarding the former, the patient was described by nursing as anxious and isolative with ongoing bodily concerns and affective restriction.  However, in mid-December 2014, the patient started to appear more positive, more relaxed and more social, which is consistent with the consolidation of treatment gains.  In terms of treatment, the patient benefited from milieu, group, individual and family therapies on the unit.  His diagnostic assessment, which had included multiple rule outs upon admission, was determined with far greater certainty.  The services provided during the disputed timeframe were for active treatment and were reasonably expected to improve his condition and prevent a more serious episode of illness.  Thus, residential treatment services provided from 11/13/14 through 12/22/14 were medically indicated for the treatment of this patient.  Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 62-year-old male enrollee has requested reimbursement for FoundationOne genomic profile tumor biomarker or gene expression testing performed on 3/01/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that atypical meningiomas are not malignant solid tumors. They are associated with a higher risk of recurrence after surgery. Further therapy may include radiation, but not typically systemic therapy. Next generation sequencing, such as with FoundationOne, is used to identify molecular markers for which targeted therapy exists, either in a clinical trial or as standard therapy. This patient would not be considered for systemic therapy based on his diagnosis, and next generation sequencing would be of limited utility in this case. Therefore, FoundationOne genomic profile tumor biomarker or gene expression testing performed on 3/01/18 was not medically necessary for the evaluation of this patient.