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

Summary Reviewer 

The patient is a 57-year-old female with a history of left knee pain. The patient has requested authorization and coverage for left knee arthroscopy with partial meniscectomy and chondroplasty. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that recent studies have conclusively shown that outcomes after an arthroscopic partial meniscectomy are no better than the outcomes after a sham/placebo surgery. Meniscal repair is now being touted as a viable and effective alternative. However, meniscal repairs depend upon the location of tear in the peripheral red zone of the meniscus. Meniscal repairs have been proven to be a much more efficient alternative to partial meniscectomy. It is now increasingly recommended to attempt meniscal repair in all repairable tears, especially in young and physically active patients. Partial meniscal implants have also shown excellent outcomes in long-term studies, but its efficacy in acute settings still requires further research. Research in regenerative medicine also looks promising for the meniscal tissue. In this case, the patient has documented degenerative changes in the medial articular surface of the patella and trochlea. The two reported tears are small and involve the inferior aspect of the medial meniscus in the posterior horn and the body. These are likely degenerative in nature. There are no mechanical symptoms documented, and the tears are stable. Focal cartilage lesions seen on MRI, such as fissuring in this case, warrant a trial of conservative treatment, such as physical therapy, home exercise program, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections or viscosupplementation, which has not been documented. Furthermore, the location of pain has not been documented to be anterior, and so it is not known if patellar chondromalacia is the pain generator. Chondroplasty has short-term efficacy for pain relief and may be done as a part of the arthroscopic procedure of partial meniscectomy, which is not indicated for the aforementioned reasons. Therefore, the requested left knee arthroscopy with partial meniscectomy and chondroplasty is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer

The patient is a 46-year-old female who has been diagnosed with metastatic signet ring cell adenosarcoma. The patient was initially diagnosed in November 2016. She is currently being treated with folinic acid, fluorouracil and oxaliplatin (FOLFOX) chemotherapy. Prior therapies have included bilateral ureteral stenting, folinic acid fluorouracil and irinotecan (FOLFIRI) and paclitaxel with ramucirumab. Based on a molecular profiling performed with FoundationOne testing, the provider recommended treatment with Cabometyx. The Health Insurer denied the request for coverage and authorization on the basis that the requested Cabometyx 60 mg is not medically necessary for the treatment of this patients medical condition. This denial is the subject of this appeal and determination. There is a lack of support for the requested medication in this clinical setting. Cabometyx (cabozantinib) is not U.S. Food and Drug Administration approved for the treatment of gastric cancer. Off-label use is not supported by major drug compendia or the National Comprehensive Cancer Network guidelines. In addition, the medical literature does not reveal clinical trials that support the use of cabozantinib for patients who are diagnosed with gastric cancer. As such, the efficacy of Cabometyx 60 mg for treatment of this patients medical condition has not been established. Therefore, for the reasons stated above, Cabometyx 60 mg is 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 45-year-old male enrollee has requested authorization and coverage for powered upper extremity range of motion assist device, elbow, wrist, hand and finger. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of the enrolleeas medical condition.  The physician reviewer found that there is a lack of support for the requested device in this clinical setting. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve his hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase his participation in bimanual activities. Winstein and colleagues reviewed the various treatments of motor dysfunction after a stroke. The authors noted that a Cochrane review found that upper limb robotic therapy provided some benefit with regard to activities of daily living and arm function, but not arm muscle strength. The guidelines indicate that these studies were noted to have numerous limitations. These limitations include the variation within the trials with regard to duration and amount of training, the specific devices used, and patient populations studied limit the interpretation of these results. McCabe and colleagues performed a small study that was retrospective with inconsistent timing of testing and limited interpretation. The authors discussed the feasibility and clinical experience of using myoelectric orthosis in rehabilitation of chronic stroke patients. The study used a small patient group and indicated that additional studies are warranted to determine the effectiveness of these methods in the clinical setting. Additional controlled studies of the MyoPro Orthosis for upper extremity paralysis after a stroke are needed with larger patient groups, consistent improvements of relevant outcome functional measures, and long-term follow-up. Therefore, the requested powered upper extremity range of motion assist device, elbow, wrist, hand and finger is not likely to be more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 45-year-old male enrollee has requested authorization and coverage for powered upper extremity range of motion assist device, elbow, wrist, hand and finger. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of the enrolleeas medical condition.  The physician reviewer found that current quality evidence shows that the use of the myoelectric elbow-wrist-hand orthosis increases gross manual dexterity, increases the quality of task performance and enables subjects to grasp objects like a cup significantly faster. Myoelectric elbow-wrist-hand orthosis facilitates clinically meaningful increases in functional task performance. Moderately impaired stroke survivors exhibit severely diminished ability to incorporate their affected upper extremities into daily activities and subsequently have limited treatment options. This limitation often necessitates prescription of compensatory strategies and/or assistive devices to facilitate  independence, with limited involvement from the paretic upper extremity, making many activities extremely difficult. In contrast, current evidence supports that paretic arm disability may be significantly reduced while wearing a myoelectric elbow-wrist-hand orthosis, allowing for immediate use of the paretic arm and hand with little device training. Therefore, the requested powered upper extremity range of motion assist device, elbow, wrist, hand and finger is likely to be more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 51-year-old female has requested reimbursement for destruction by neurolytic agent (CPT codes 64635 and 64636) performed on 12/02/13 and 12/23/13.  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 records indicate that the patient underwent cooled radiofrequency lesioning.  Of note, cooled radiofrequency lesioning is a newer technology that does not have the same peer-reviewed evidence of duration and efficacy as conventional radiofrequency lesioning.  Although the current literature on cooled radiofrequency lesioning is promising, more extensive studies need to be conducted against the standard approach.  Therefore, the services at issue performed on 12/02/13 and 12/23/13 were not likely to be of greater benefit than other treatment alternatives.  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 2


A 51-year-old female has requested reimbursement for destruction by neurolytic agent (CPT codes 64635 and 64636) performed on 12/02/13 and 12/23/13.  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 there is sufficient support for the services at issue in this patients case.  Lumbar medial branch radiofrequency ablation or neurolysis is a well-documented procedure which may help with chronic low back pain due to lumbar facet pain.  The medical records support the services at issue in this clinical setting.  The literature has noted the effectiveness of medial branch radiofrequency neurotomy in systematic reviews and randomized trials.  In sum, the services at issue performed on 12/02/13 and 12/23/13 were likely to have been more effective than other treatment options.  Based upon the information set forth above, the services at issue were 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


A 51-year-old female has requested reimbursement for destruction by neurolytic agent (CPT codes 64635 and 64636) performed on 12/02/13 and 12/23/13.  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 there is sufficient support for the services at issue in this clinical setting.  This patient had both axial and radicular pain complaints.  The right lumbar medial branch nerve blocks and cooled lumbar medial branch nerve radiofrequency ablation at L3, L4, and L5 were aimed at the axial component of the back pain.  Radiofrequency ablation is a standard, widely accepted treatment for axial lumbar back pain.  Thus, the services at issue performed on 12/02/13 and 12/23/13 were likely to have been superior over other treatment alternatives.  Based upon the information set forth above, the services at issue were 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 1

A 30-year-old female enrollee has requested reimbursement for bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient presented with a longstanding history of bilateral severe hallux valgus deformity, left greater than right. She complained of pain with weight-bearing. Conservative treatment had included activity modification, bracing, wide shoes, and nonsteroidal anti-inflammatory drugs. She had a left hallux valgus angle (HVA) of 35 degrees, and intermetatarsal angle (IMA) of 15 degrees. She had a right HVA of 35 degrees, and intermetatarsal angle (IMA) of 18 degrees. She underwent left chevron osteotomy and modified McBride procedure with x-ray fluoroscopy on 6/10/19, and right scarf osteotomy and modified McBride procedure with x-ray fluoroscopy on 7/29/19. Current evidence-based medical literature supports the use of surgical treatment of hallux valgus in this clinical setting, given the severity of the HVA and IMR angles, significant pain and functional impairment, and failure of non-operative treatment. Additionally, there is no indication in the literature to support ongoing conservative treatment over surgical correction in the setting of severe deformity. Therefore, bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19 was likely to have been more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 30-year-old female enrollee has requested reimbursement for bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the non-surgical treatment is the initial treatment of choice for symptomatic hallux valgus deformity. Shoe modification, padding and local application of ice to symptomatic bunion are reasonable initial conservative options. Orthotic devices to control documented biomechanical dysfunction may be considered as conservative or post-surgical options. Surgical treatment is recommended if there is no or little response to non-operative treatment after a six-month trial, or if initial response deteriorates. In general, once surgical criteria has been met, the surgical procedures to be performed are based on the location and the degree of deformity. The two most common radiographic measurement used to choose appropriate surgical procedures include the intermetatarsal angle (IMA) and the hallux valgus angle (HVA). For IMAs less than 13 degrees, distal osteotomy or soft tissue procedure alone are sufficient to correct the deformity. For IMAs greater than 13 degrees, a proximal osteotomy is recommended. There is a variety of osteotomies described to correct the IMA, including the scarf, and no procedure has proved superiority over the other. Regarding the HVA, angles less than 30 degrees can be treated with a distal soft tissue procedure, such as the modified McBride procedure, with or without a chevron osteotomy. For HVA greater than 40 degrees, metatarsophalangeal joint fusion is generally recommended.
In this patients case, operative criteria have been met. Based on the radiographs and the HVA and IMA measurements reported by the treating surgeon, appropriate surgical procedures were performed and are supported by published treatment guidelines for the treatment of symptomatic hallux valgus. In sum, bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19 was likely to have been more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 30-year-old female enrollee has requested reimbursement for bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient had a history of bilateral hallux valgus deformities, and she underwent surgery for correction of this painful deformity. The provider elected to perform the modified McBride procedure combined with a chevron osteotomy of the left great toe on 6/10/19 and a modified McBride procedure combined with a scarf osteotomy of the right great toe on 7/29/19. Fluoroscopy was utilized for both surgical procedures. Hallux valgus deformity is a common chronic problem, and its chief complaint is pain. The procedures performed, including the modified McBride, chevron osteotomy, and scarf osteotomy, are all current procedures with documented good results. There is sufficient support for the services at issue in this clinical setting. Thus, bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19 was likely to have been more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 60-year-old male enrollee has requested reimbursement for Oncotype DX Genomic Prostate Score performed on 5/16/19. 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 the National Comprehensive Cancer Network (NCCN) recommends that men who are status post biopsy with low or favorable intermediate risk disease may consider the use of the Oncotype DX testing. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of NCCN risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy, and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays.  It is considered a standard of care in guiding treatment decision making. Therefore, the Oncotype DX Genomic Prostate Score performed on 5/16/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 64-year-old male enrollee has requested reimbursement for air ambulance transport on 7/19/14 through 7/20/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the review of the submitted evidence demonstrates the patient was involved in a serious motor vehicle accident on 7/2/14, resulting in multiple life-threatening injuries and requiring air transportation to the nearest hospital for stabilization and intensive medical treatment. The patients condition initially required placement on life support with subsequent sedation and was further complicated by underlying medical problems, such as a history of prior lung cancer. Open and active communication among the members of the medical team and the family, and later with the injured person, is of significant importance in this setting in order to consistently match the medical care to the injured persons needs and goals and to maximize subsequent recovery. Further, these extensive injuries typically require prolonged and aggressive medical treatment in order to have the best possible ultimate recovery, function and speech, and ability to think clearly. According to the submitted documentation, the hospital nearest to the accident site was able to provide the technical medical skills that the patient required. However, the significant language barrier prevented the open and active communication that was necessary, and this was likely to interfere with the patients overall medical care and subsequent recovery.  Transportation to a facility that had English-speaking medical team members was therefore necessary. However, there were a number of such facilities in Italy and other nearby countries that could meet these criteria. Further, the patients overall condition at the time of the transfer was somewhat tenuous. Shorter transportation time may have placed less physical stress on the body while in this state and would have also returned the patient to a more controlled intensive medical environment faster. For these reasons, air ambulance transportation from Pisa, Italy to the receiving hospital in California was not medically necessary. For the reasons stated above, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 60-year-old male enrollee has requested reimbursement for chiropractic services including CPT codes 97110, 97032, 97140 and 99214 provided on 6/1/17, 6/8/17, 6/15/17, 8/14/17, and 9/7/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees spondylosis without myelopathy/radiculopathy of the cervical region. The physician reviewer found that the provided documentation does not establish the medical necessity of the chiropractic services provided from 6/1/17 through 9/7/17. Specifically, the records do not objectively verify functional improvements with prior chiropractic therapy over eight weeks of care. As noted in the current medical literature and guidelines, the documentation should report objective functional improvement with chiropractic treatment to support an indication for future services. Accordingly, the chiropractic services including CPT codes 97110, 97032, 97140 and 99214 provided on 6/1/17, 6/8/17, 6/15/17, 8/14/17, and 9/7/17 were not medically necessary for treatment of this patients neck pain and low back pain. Based on the foregoing discussion, 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 51-year-old female enrollee has requested reimbursement for mental health residential treatment from 5/13/15 through 6/07/15. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees alcohol use disorder. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  In this case, the patients alcohol use disorder was complicated by co-occurring mood and anxiety disorders.  He alcohol use dominated her daily routine and generated distress.  Further, her drinking negatively impacted her health, strained meaningful relationships, and caused significant impairment across multiple domains of functionality.  Additionally, her motivation and social supports were limited.  In this patients case, the residential treatment provided was safe, appropriate and consistent with good practice.  Additionally, the services provided during the disputed timeframe were for active treatment, and reasonably expected to improve her condition and prevent a more serious episode of illness.  Further, the duration of the disputed treatment course was within community practice standards.  All told, mental health residential treatment provided from 5/13/15 through 6/07/15 was 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.