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

Summary Reviewer 2

A 46-year-old female enrollee has requested authorization and coverage for ketamine infusion and one day inpatient stay. The Health Insurer has denied this request indicating that the requested services are considered experimental/investigational for treatment of the enrollees peripheral neuropathy status post chemotherapy treatment. The physician reviewer found the requested services are not likely to be more effective for this patient than other available treatment options. The medical records provided for review report a condition of chronic pain with diagnosis of small fiber neuropathy (biopsy proven) with a history of chemotherapy for breast cancer.  The medical records also report complex regional pain syndrome (CRPS), but the documentation submitted for review does not detail specific information in support of this diagnosis. The medical records report failure of interventional, physical and psychological modalities, but the documentation does not detail the particular treatments or duration of those treatments in support that all standard treatments have not helped. Kosharskyy and colleagues note that ketamine infusions may have benefit for CRPS; however there is insufficient evidence in regards to neuropathy related pain.  In addition, there is a lack of medical literature of standardized dosing regimen or duration of such therapy in regard to peripheral neuropathy/small fiber neuropathy pain.  All told, the peer reviewed literature does not support ketamine infusion as likely to be more beneficial for treatment of the patients medical condition than other modalities for the treatment of peripheral neuropathy related pain. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 46-year-old female enrollee has requested authorization and coverage for ketamine infusion and one day inpatient stay. The Health Insurer has denied this request indicating that the requested services are considered experimental/investigational for treatment of the enrollees peripheral neuropathy status post chemotherapy treatment. The physician reviewer found based on the documentation submitted for review, there is a lack of support demonstrating a diagnosis of complex regional pain syndrome. In addition, the current research is inconclusive in regards to ketamine for the treatment of chemotherapy induced peripheral neuropathy, which the patient does have a diagnosis (Hershman, et al; Ewertz, et al). In addition, ketamine does not help for all types of neuropathic pain and research is still ongoing (OBrien, et al). For the reasons provided, the request for inpatient ketamine infusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. 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 Overturned

Summary Reviewer 1

A 68-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees atrial fibrillation. The physician reviewer found that patient has an absolute indication for anticoagulation therapy, but he had a major gastrointestinal bleed while on anticoagulation therapy. His provider noted that the patient remains at risk for recurrent gastrointestinal bleeding if he remains on the required lifelong anticoagulation. The Watchman device can obviate the need for long-term anticoagulation in patients at risk for significant bleeding, as is the case with this patient. The Watchman device is both a safe and effective alternative to prevent recurrent stroke in patients with persistent atrial fibrillation who are at high bleeding risk during long-term anticoagulation therapy. Therefore, the requested percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device) is likely to be of greater benefit than other methods of evaluating this patient. 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 Overturned

Summary Reviewer 2

A 68-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees atrial fibrillation. The physician reviewer found that in this circumstance, atrial fibrillation treatment options include continuation of anticoagulation while accepting an increased bleeding risk or percutaneous left atrial appendage exclusion using a Watchman device. The U.S. Food and Drug Administration (FDA) has approved the Watchman device. The Watchman device is an appropriate alternative in patients who are deemed to be at prohibitively high bleeding risk while on long-term anticoagulation, such as is documented with this patient. The requested services are likely to be more beneficial than the alternative of long-term anticoagulation in this patient with a documented high risk of recurrent bleeding. In sum, the requested percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device) is likely to be more efficacious than other available treatment options. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 68-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees atrial fibrillation. The physician reviewer found that the Watchman device is an effective and relatively safe option for patients with atrial fibrillation who require but cannot take long-term anticoagulation. However, this patient underwent successful atrial fibrillation ablation with no documented recurrence of atrial fibrillation when the device had been regularly interrogated. Therefore, long-term anticoagulation would not be indicated to justify the need for a Watchman device. Thus, the superior efficacy of the requested percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device) has not been demonstrated. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 56-year-old female enrollee has requested reimbursement for magnetic resonance imaging (MRI) of the lumbar spine provided on 10/27/17. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was not medically necessary for evaluation of the enrollees left-sided back and hip pain. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The American College of Radiology (ACR) indicates that MRI is not warranted in the acute setting. However, in the setting of low back pain in which the patient is a candidate for surgery or other intervention, then the ACR considers MRI to be the most appropriate study, with no stipulation about delaying the MRI. In 2007, Chou and colleagues noted that clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain. Per the authors clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy). In general, plain x-rays are often of very limited value. Plain x-rays serve to evaluate the patient for significant structural abnormalities, such as fractures, malalignments or congenital anomalies. However, plain x-rays are not generally beneficial for evaluating the patient for a cause for radiculopathy. Patients can have significant disc herniations with normal plain x-rays; and conversely, patients with significant degenerative change in the lumbar spine may not have significant disc encroachment. Most importantly, many patients have radiographic and/or MRI evidence of degenerative changes with apparent disc herniations, and are asymptomatic. Thus, radiographic findings do not necessarily correlate with clinical symptoms, and it is imperative that decisions are based on symptoms. There is a lack of support for the diagnostic procedure at issue in this patients case. The only reason to obtain an MRI is in anticipation of some sort of intervention. This could be surgery, but it could also involve facet injections. Prior to an intervention, it is not unreasonable to attempt a trial of conservative treatment, such as physical therapy, a targeted exercise program, or methodical use of anti-inflammatory drugs. In sum, MRI of the lumbar spine provided on 10/27/17 was not medically necessary. Therefore, the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

An 18-year-old male has requested authorization and coverage for Qbrexza. 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 according to a recent review published in the American Academy of Dermatology, first-line treatment for primary axially hyperhidrosis is topical antiperspirants. The patient has already tried and failed Drysol, a commonly used first-line antiperspirant. His provider has recommended that the patient continue to use Qbrexa, which is also a topical antiperspirant and is U.S. Food and Drug Administration (FDA) approved for use in axillary hyperhidrosis. Additionally, the International Hyperhidrosis Society considers Qbrexa as first-line treatment for axillary hyperhidrosis. There is sufficient support for the requested medication in this clinical setting. Therefore, Qbrexa is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 54-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/06/16.  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 provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  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 54-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/06/16.  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 the current medical evidence supports the service at issue in this clinical setting.  According to Skaane and colleague, 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.  Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  In sum, digital breast tomosynthesis performed on 7/06/16 was likely to have been more effective 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 54-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/06/16.  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 (CT) 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.  There is sufficient support for the service at issue in this clinical setting.  In this patients case, it was not unreasonable to perform surveillance mammography with the addition of tomosynthesis despite of the non-dense nature of her left breast, as there is an increased risk of developing a contralateral carcinoma.  Thus, digital breast tomosynthesis performed on 7/06/16 was likely to have been superior over 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 Upheld

Summary Reviewer 1

A 52-year-old male enrollee has requested authorization and coverage for implant stimulator.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees complex regional pain syndrome to his right foot. The physician reviewer found that there is a lack of support for the superior efficacy of the requested services in this clinical setting. This patient is being treated for chronic right lower extremity pain including a diagnosis of CRPS. He has a spinal cord stimulator. In terms of dorsal root ganglion (DRG) spinal cord stimulation, this modality is considered to be comparable to traditional spinal cord stimulator in terms of pain relief and associated benefits. The positional nature of the current coverage indicates that an assessment of the reason for inadequate coverage should be performed. Lead migration may have occurred or there may be failure of the generator or other components. Attempts at reprogramming or lead revision would be alternatives. As such, an implant stimulator for the treatment of the patients medical condition is not likely to be more effective than the available standard therapy.Therefore, for the reasons stated 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 52-year-old male enrollee has requested authorization and coverage for implant stimulator.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees complex regional pain syndrome to his right foot. The physician reviewer found that there is some support for the requested services in this patients case. The patient has severe CRPS of the right foot and has been non-responsive to a variety of interventional options including intrathecal pump and traditional spinal cord stimulation stimulator. The patients pain pattern is amenable to DRG stimulation along the lower lumbar nerve roots. DRG stimulation is proven to have long-term benefit for CRPS when other modalities have failed and is likely to be more effective than any other available standard therapy for the treatment of this patients medical condition. Therefore, for the reasons stated 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 52-year-old male enrollee has requested authorization and coverage for implant stimulator.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees complex regional pain syndrome to his right foot. The physician reviewer found that the medical records provided for review indicate a condition of chronic back pain with degenerative disc disease and previous spine surgery.  There is documentation regarding previous conservative care and treatment response to date but also notes little improvement with spinal cord stimulator trial. However, implanted stimulator, permanent placement is not supported unless at least 50% improvement in pain with demonstrated functional gain. Babu and colleagues reported that permanent placement outcomes are maximized when at least 50% improvement in pain and functional gain is used to measure success. Provenzano and colleagues noted the effectiveness of implanted stimulator but reflects that placement is only supported for those cases with demonstrated functional improvement. The medical records provided do not indicate that this threshold has been met in this patient.  In sum, spinal cord stimulation permanent placement is not likely to be more efficacious in this patients case than the standard options available for treatment. Therefore, for the reasons stated 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 parent of an eight-year-old male enrollee has requested authorization and coverage for applied behavioral analysis (ABA) therapy. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees autism spectrum disorder. The physician reviewer found that ABA therapy is generally accepted as being an appropriate and recommended treatment for children with autism spectrum disorder. Common features of ABA-based therapies include the objective measurement of behavior, structured control of the environment, and the implementation of procedures based on scientifically established principles of behavior. An extensive body of scientific literature demonstrates the success of ABA-based interventions to decrease problem behavior and increase skills in adults and children with intellectual disabilities and autism. Several meta-analyses indicate that comprehensive ABA intervention leads to medium to large effects in terms of intellectual functioning, acquisition of daily living skills, social functioning and language development in children with autism (Virues-Ortega; Kahng, et al; Lilienfeld). Numerous scientific organizations have concluded that ABA-based therapies are highly effective in the treatment of autism. In this case, ABA therapy is medically necessary to address the patients aggressive behavior, rigidity of routine, and difficulty with social interactions. 
Therefore, the requested services are 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 61-year-old male enrollee has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees prostate cancer. The physician reviewer found that currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Sheets and colleagues evaluated the comparative effectiveness of intensity modulated radiation therapy (IMRT), proton beam therapy, and conformal radiation therapy for prostate cancer. In the comparison between IMRT and proton therapy, IMRT patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities between IMRT and proton therapy. Yu and colleagues performed an analysis of early toxicity and compared 421 patients treated for prostate cancer with proton therapy and 842 matched case controls treated with IMRT. There was a statistically significant decrease in genitourinary toxicity at six months with proton therapy; however, this difference disappeared by one year. There were no other significant differences in toxicity between the two techniques. A position statement released by American Society of Radiation Oncology (ASTRO) in 2013 stated, At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. Therefore, proton beam therapy is not medically necessary for the treatment of this patient.