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

Summary Reviewer 1


A 50-year-old female enrollee has requested reimbursement for Afirma gene testing performed on 7/22/14. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. While a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate (Alexander, et al). Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign (Miller, et al). A relatively new test, the Afirma Thyroid FNA Analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. Based on the support in the peer-reviewed literature and clinical documentation submitted, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than other modalities.Based upon the information set forth above, the testing 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 50-year-old female enrollee has requested reimbursement for Afirma gene testing performed on 7/22/14. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that The American Thyroid Association (ATA) guidelines state For nodules with [atypia of undetermined significance/follicular lesion of undetermined significance] AUS/FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. In this case the patient had a cytopathology result consistent with atypia of undetermined significance (AUS). Without this test, the patient would have required a second biopsy or surgery to clarify the diagnosis. Therefore the submission of the specimen to Afirma gene expression classifier was appropriate. The result was noted as suspicious which indicated a risk of malignancy of 40% in that nodule (Alexander, et al). The increased risk of malignancy justifies the decision to perform a thyroidectomy. With the size of the nodule the extension of the surgery can also be determined from the result. A benign result would have prevented an unnecessary surgery and its potential comorbidities. All told, the Afirma gene testing performed on 7/22/14 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was 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 50-year-old female enrollee has requested reimbursement for Afirma gene testing performed on 7/22/14. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Over the last few years gene testing analysis has become standard of care for analyzing thyroid nodules with a cytologic diagnosis of atypia of undetermined significance or follicular lesion of undetermined significance. This patient is precisely the type of patient that would benefit from this type of analysis. Therefore, the Afirma gene testing performed on 7/22/14 was likely to be more beneficial than other modalities. Based upon the information set forth above, the testing 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 

A 61-year-old male enrollee has requested authorization and coverage for Androgel. 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 in this case, the patient has symptoms of hypogonadism and one test result available consistent with low testosterone level. The records do not document a second test confirming the low testosterone. The records do not document whether there was a diagnostic work-up for hypogonadism, such as determining whether it is primary or secondary. The records do not show whether this patient has been counseled regarding the possible side effects of testosterone replacement, or that he is being monitored. It is recommended that complete blood count, a prostate-specific antigen (PSA) level or a prostate examination be done prior to starting therapy and to monitor after initiation of testosterone. The patient is on Proscar, which is a medication for treatment of enlarged prostate and benign prostatic hyperplasia. It is well-documented that testosterone replacement might contribute to prostate cancer. Therefore, patients at risk for prostate cancer should avoid testosterone replacement therapy and should be evaluated by a urologist. Thus, Androgel is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 49-year-old female enrollee has requested reimbursement for the arthrodesis, interbody fusion, discectomy, decompression and related services provided on 9/6/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees left arm pain and neck pain with cervical kyphotic deformity and grade 1 spondylolisthesis at C4-5.  The physician reviewer found that the available medical records document the presence of degenerative spondylolisthesis and associated radiculopathy and myelopathy. Thus, anterior cervical discectomy and fusion was medically necessary in the presence of extensive degenerative disc disease with degenerative spondylolisthesis and clinical evidence of radiculopathy and myelopathy. However, the currently available evidence is insufficient to support the use of mesenchymal stem cells in this procedure (Khashan, et al; McAnany, et al). Given these findings, the surgery including the C4-5 anterior cervical discectomy and fusion using interbody PEEK cage and allograft, C5-6 anterior cervical discectomy and fusion using interbody PEEK cage and allograft, and C6-7 anterior cervical discectomy and fusion using interbody PEEK cage and allograft, bilateral foraminotomies at C4-5, C5-6, and C6-7, and placement of anterior cervical plate at C4-7 using NuVasive system, fluoroscopic guidance, and reduction of kyphotic deformity was appropriate, reasonable, and medically necessary, and the stem cell portion of the procedure of 9/6/16 was not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 60-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 9/22/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer.   The physician reviewer found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed on 9/22/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 60-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 9/22/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer.   The physician reviewer found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis performed on 9/22/16 was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. 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 60-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 9/22/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer.   The physician reviewer found that 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 (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. This particular patient has breasts that have been described as extremely dense. It is specifically patients with dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures better enables the possibility of demonstrating an otherwise occult tumor. The sonogram is also of value, as sonography will help visualize the cystic lesions. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 9/22/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Based upon the information set forth above, the 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 Upheld

Summary Reviewer 1

A 49-year-old male enrollee has requested reimbursement for CPT 83516 (Immunoassay, nonantibody) performed on 7/20/19. 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 distinguishing between type 1 and unusual presentations of type 2 diabetes can sometimes be difficult. The presence of antibodies to glutamic acid decarboxylase (GAD) in patients with presumed type 2 diabetes can help identify patients who may have type 1 diabetes. Autoantibody measurement is indicated when the diagnosis of type 1 or type 2 diabetes is uncertain by clinical presentation, when there is a personal or family history of autoimmune disease, or in overweight or obese children or adolescents presenting with apparent type 2 diabetes, who actually may have an early presentation of type 1 diabetes. In this case, the patient has a history of type 2 diabetes with typical presentation, and no personal or family history of autoimmune disease. Although he had an episode of ketoacidosis, this was the unusual case of a type 2 diabetic presenting with ketoacidosis due to an acute illness (i.e. pulmonary embolism). There is a lack of support for the services at issue in this clinical setting. Therefore, CPT 83516 performed on 7/20/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 49-year-old male enrollee has requested reimbursement for CPT 83516 (Immunoassay, nonantibody) performed on 7/20/19. 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 this patient had type 2 diabetes and a history of pulmonary embolism. He presented for a routine examination. On 7/08/19, the patient reported no complaints. Prostate-specific antigen testing was ordered as well as CPT code 83516. There is no diagnosis of keratoconjunctivitis, sicca syndrome or inflammatory dry eye syndrome. The patient had no examination findings or other abnormal laboratory testing. The diagnosis of diabetes mellitus or pulmonary embolism does not necessitate the requested test of CPT 83516, immunoassay, non-antibody. In sum, CPT 83516 performed on 7/20/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 49-year-old male enrollee has requested reimbursement for CPT 83516 (Immunoassay, nonantibody) performed on 7/20/19. 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 this patient has type 2 diabetes. The assay ordered was an immunoassay for analyte other than infectious agent antibody or infectious agent antigen. The diagnosis code used for testing was for type 2 diabetes. In this case, there is no documentation that would support the need for the services at issue. There is no documented relationship between type 2 diabetes and the testing at issue. Furthermore, monitoring of control of type 2 diabetes is with hemoglobin A1C. There is no documentation that the patient had symptoms that would be concerning for poorly controlled diabetes mellitus or any complications with the diabetes. Thus, CPT 83516 performed on 7/20/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 54-year-old male enrollee has requested reimbursement for air ambulance services provided on 5/12/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees brain tumor with mass effect and parenchymal hemorrhage. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the services at issue. Pituitary apoplexy is considered an acute neurosurgical life threatening, emergency (Post et al; Briet et al; Vanderpump, et al). The potential for acute hemorrhage,  acute pituitary collapse with adrenal insufficiency, and blindness  requires emergency care and treatment (Muthukumar, et al; Nawar, et al; Rajasekaran, et al). Not all hospitals have the combination of neurosurgical with transsphenoidal abilities/endocrinologic/ophthalmologic and intensive care facilities. These services are a must for proper care of pituitary apoplexy (Rajasekaran, et al). In this clinical setting, UCSF was a closer facility with these capabilities than UCSD. Therefore, the ambulance services provided on 5/12/14 was not medically necessary in this patients case. For the reasons provided, 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 Overturned

Summary Reviewer 1

The patient is a 64-year-old female with a history of severe sleep apnea. The records document an apnea-hypopnea index of 43.0 per a sleep study dated 10/12/17. She had no central apneas. She has tried a continuous positive airway pressure (CPAP) device, but has not been able to tolerate it. She is status post septoplasty and turbinate reduction, without improvement. The patient has requested coverage for an implanted nerve stimulator. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of this patient.  This patient has severe obstructive sleep apnea and has not been able to tolerate the CPAP device. She has undergone septoplasty and turbinate reduction, which has not improved her condition. The Inspire device is medically appropriate in this clinical setting. Her body mass index is below 32. This patient is a candidate for the Inspire device. Therefore, the implanted nerve stimulator is likely to be more efficacious than other treatment options in this patients case. Based upon the information set forth above, the requested device is 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 patient is a 64-year-old female with severe obstructive sleep apnea. The medical records document a history of unsuccessful attempts to utilize the gold standard treatment of continuous positive airway pressure (CPAP) therapy. On 9/12/17, the records noted a body mass index of 20.2. On 9/26/17, septoplasty and bilateral inferior turbinate reduction was performed. On 10/12/17, a home sleep study confirmed that the patient had a total of 162 obstructive apnea episodes, without central apnea. The documentation noted an apnea-hypopnea index of 43.0 episodes per hour of sleep. The patient has requested coverage for an implanted nerve stimulator. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of this patient.  There is sufficient support for the requested device in this clinical setting. This patient meets clinical criteria for consideration of surgical management of her obstructive sleep apnea symptoms. Prior evaluation has documented the degree of obstructive sleep apnea to be severe. The patient had trialed CPAP therapy for airway management and was intolerant to the use of this device. Clinical studies indicate that patients only benefit from this device when they have a body mass index less than 32, and the patient meets this criteria. Per the medical evidence, patients achieve a definite benefit from the implantation and electrical stimulation of the hypoglossal nerve for treatment of this disorder. All told, the requested implanted nerve stimulator is likely to be superior over other available treatment options. Based upon the information set forth above, the requested device is 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 patient is a 64-year-old female with a history of severe obstructive sleep apnea as diagnosed from a home sleep study. She was treated with continuous positive airway pressure (CPAP), but was unable to tolerate this therapy. The patient is status post septoplasty and bilateral inferior turbinate reduction. The patient has requested coverage for an implanted nerve stimulator. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of this patient.  The submitted documentation fails to demonstrate the superior efficacy of the requested device. A home sleep study performed on 10/12/17 showed an apnea-hypopnea index of 43.0.  The records do not document what measures were done to help the patient tolerate CPAP. Positive airway pressure therapy is the gold standard in this clinical setting. Thus, implanted nerve stimulator is not likely to be more effective than other treatment options. Based upon the information set forth above, the requested device is 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 1

A 24-year-old female enrollee has requested reimbursement for 83993 (fecal calprotectin) provided on 1/30/18. 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 diarrhea. The physician reviewer found that Calprotectin is a zinc and calcium binding protein that is derived mostly from neutrophils and monocytes. It can be detected in stool, making it a valuable marker of neutrophil activity. Fecal calprotectin levels are increased in intestinal inflammation and may be useful for distinguishing inflammatory from noninflammatory causes of chronic diarrhea. Fecal calprotectin can be considered as an adjunctive test in diagnostic evaluation of patients with chronic diarrhea. Therefore, for 83993 (fecal calprotectin) provided on 1/30/18 was likely to have been superior over other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.