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

Summary Reviewer 3


A 53-year-old male enrollee has requested reimbursement for the bronchial thermoplasty provided from 1/21/15 through 4/8/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees persistent asthma.  The physician reviewer found that bronchial thermoplasty is a procedure that uses a bronchoscope probe/catheter to provide thermal energy to the smooth muscle of the airway. The tissue is heated to 65 degrees Centigrade. There are three bronchoscopic procedures. The first procedure treats the right lower lobe, the second focused on the left lower lobe, and the third procedure is for both upper lobes. The procedures are scheduled three weeks apart. The provider states that bronchial thermoplasty has been U.S. Food and Drug Administration (FDA) approved for the treatment of patients with asthma. However, bronchial thermoplasty has not been FDA approved for use in this clinical setting. Further, there is a paucity of data from well designed, randomized, controlled clinical trials demonstrating the long-term safety and efficacy of the device for use as a generally accepted, standard of care for the treatment of asthma. The provider states the patient has a progressive decrease in the quality of life but there is no documentation that the use bronchial thermoplasty would improve the long-term functional outcome of the patients condition. For these reasons, the bronchial thermoplasty services provided from 1/21/15 through 4/8/15 were 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 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer

The patient is a 32-year-old male with a history of thoracic spine pain and T11-12 degenerative disc disease. On 12/22/17, the patient was treated with a bilateral T11-12 epidural steroid injection. Per the records, this provided good, but temporary, relief. The enrollee was also treated with physical therapy, chiropractic care, and massage. The provider has recommended transformational lumbar interbody fusion (TLIF). The patient has requested coverage for spinal fusion surgery. The Health Insurer has denied this request indicating 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 submitted documentation fails to demonstrate the medical necessity of the requested services. The 2009 American Pain Society guidelines indicate that spinal fusion surgery is not better than intensive rehabilitation for pain associated with degenerative changes (non-radicular). Per the medical records submitted, the patient does not meet this standard. The patient does not have radicular disease with neurological deficits, and he does not have spinal instability, fracture or tumor. Thus, the requested spinal fusion surgery is not medically necessary for the treatment of this patient. Therefore, the requested services are 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 

The patient is a 56-year-old female with osteoporosis. Her provider has prescribed Prolia for the treatment of this condition. The patient has requested authorization and coverage for Prolia 60 mg injected every six months for one year.  The physician reviewer found that the patient has been diagnosed with osteoporosis. Four agents (alendronate, risedronate, zoledronic acid and denosumab) have evidence for broad spectrum anti-fracture efficacy and should generally be considered as initial options for most patients who are candidates for treatment. There is a lack of head-to-head trials with a preplanned endpoints of fractures comparing one drug with another. Bisphosphonates (alendronate, risedronate and zoledronic acid) are usually the first-line of therapy. Prolia (denosumab) has been approved by the U.S. Food and Drug Administration for the treatment of osteoporosis in postmenopausal women at high-risk of fracture. Denosumab reduces the incidence of vertebral fractures by about 68%, hip fractures by about 40% and nonvertebral fractures by about 20% over three years. Per the medical evidence, Prolia is likely to be effective in treating the patients osteoporosis and in decreasing the risk of bone fracture. Therefore, Prolia 60 mg injected every six months for one year is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 58-year-old female enrollee has requested reimbursement for autonomic nerve testing performed on 9/03/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting.  Limb pain is a symptom, not a diagnosis.  In this case, the medical records do not detail history or examination features that would suggest autonomic dysfunction.  Details of electrodiagnostic tests are not available for review.  Autonomic nerve testing has been determined to be useful in evaluation of syncope and of small fiber neuropathy.  The medical literature in these circumstances is mixed at best, with a lack of high quality, randomized studies.  In this patients case, there is not documentation in the submitted records which suggest need for autonomic testing.  All told, autonomic nerve testing performed on 9/03/15 was not likely to have been superior over other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation 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 58-year-old female enrollee has requested reimbursement for autonomic nerve testing performed on 9/03/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the medical records provided for review does not support the autonomic nerve testing performed on 9/03/15.  The available medical records do not indicate any focal neurologic disturbance in regards to motor, sensory, reflex, coordination, gait or cranial nerve or cognitive function.  The records do not report by history the presence of any issue of labile blood pressure, orthostatic hypotension, or passing out episodes.  There is no indication of neuropathic pain being reported in terms of having hypersensitivity, allodynia.  Autonomic nervous system testing is useful for evaluation of autonomic nervous system when there are autonomic nervous system related symptoms. The available medical records provided for review does not support the presence of subjective symptoms consistent with autonomic nervous system abnormality or indicate objective findings on physical examination which support autonomic nervous system dysfunction.  In sum, the superior efficacy of autonomic nerve testing performed on 9/03/15 has not been established.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation 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 58-year-old female enrollee has requested reimbursement for autonomic nerve testing performed on 9/03/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting.  Autonomic testing is reserved for clinical presentations where autonomic abnormalities are part of the presenting symptoms, which are absent in this patients case.  Sudomotor testing is indicated for possible diabetic neuropathy and is not currently an accepted standard of care in the evaluation of limb pain.  Thus, the superior efficacy of autonomic nerve testing performed on 9/03/15 has not been established.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation 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 42-year-old female enrollee has requested reimbursement for DecisionDx Melanoma testing (84999) performed on 1/23/17. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the DecisionDx Melanoma has shown some accuracy determining risk of metastasis in thin melanomas, however treatment of this patient would not change based on the results of the exam. The testing at issue is not considered routine standard of care. There is a lack of peer-reviewed literature to support improved health outcomes in patients with thin melanomas. Therefore, the DecisionDx Melanoma testing (84999) performed on 1/23/17 was not 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 not likely to be more beneficial for evaluation 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 42-year-old female enrollee has requested reimbursement for DecisionDx Melanoma testing (84999) performed on 1/23/17. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Although DecisionDx Melanoma may be an independent predictor of metastasis risk, there is a lack of peer-reviewed published studies confirming this hypothesis. For this reason, the DecisionDx Melanoma testing (CPT code 84999) performed on 1/23/17 was not 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 not likely to be more beneficial for evaluation 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 42-year-old female enrollee has requested reimbursement for DecisionDx Melanoma testing (84999) performed on 1/23/17. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx Melanoma assay should not be used outside of a clinical trial setting. The use of DecisionDx Melanoma testing is not considered to be standard of care in the treatment of the patients melanoma. Thus, its usage is not expected to impact the treatment or outcome of the patients melanoma. All told, the DecisionDx Melanoma testing (CPT code 84999) performed on 1/23/17 was not 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 not likely to be more beneficial for evaluation 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 63-year-old female enrollee has requested reimbursement for inpatient hospitalization services provided from 3/19/18 through 3/20/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees low back pain. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. Her pain was controlled with oral medications, and there was no indication for significant neurologic compromise or infection. All told, inpatient hospitalization services provided from 3/19/18 through 3/20/18 were not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

The patient is a 46-year-old female with a history of left abdominal pain and left hip pain. The patient reported that she has experienced pain on the left side since the spring of 2016. She has been seen by urologist and gynecologist. Physical therapies were prescribed. An orthopedic provider recommended fluoroscopically guided injection into hip joint. The patient reported that her pain was relieved. On 12/22/16 magnetic resonance imaging (MRI) was performed. MRI of the hip noted complex tear anterior left acetabular labrum, full thickness of labral base. The tear was best seen in sagittal fat saturated proton density left hip sequence.  On 1/31/17, an operative note indicated that preoperative and postoperative diagnosis was left hip pain, labral tear and impingement. Postoperative diagnosis noted degenerative labral tearing left hip pincer type impingement. Procedure left hip arthroscopic pincer lesion resection and labral debridement were performed. The following were indications for surgery: pain relief response on injection and MRI showing complex labral tear with possible cam type impingement. The summary of intraoperative findings: mild degenerative joint disease left hip, small area of fissuring and cartilage softening, extensive degenerative labral tearing, pincer lesion between 11 and 12 oclock with no obvious CAM lesion. The patient has requested reimbursement for hip surgery performed on 1/31/17. The Health Insurer has denied this request on the basis that the services at issue were investigational for treatment of this patients medical condition. There is sufficient support for the efficacy of the services at issue in this clinical setting. Femoroacetabular impingement syndrome and its treatment is now well established and the technical requirements are well within the experience of an orthopedic surgeon skilled in arthroscopic techniques. The study published by Ganz and colleagues includes two year follow-up with improved ranges of motion and reduction in pain. This procedure involved dislocation of the hip and because of that there is added potential for morbidity. An extra-articular approach using an arthroscopic technique is reasonable and has been technically well developed. In a study by Espinosa and colleagues, extra-articular surgery with labral refixation was followed in a two year follow-up period with 48% good results, 20% moderate results and 4% poor results. The studies cited are level III and level IV studies. As such, the hip surgery performed on 1/31/17 was likely to have been more effective for treatment of the patients medical condition than any available standard therapy. 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

The patient is a 46-year-old female with a history of left groin pain related to a labral tear and pincer type femoroacetabular impingement. She tried nonoperative treatment including medications, physical therapy, rest, and avoidance of sports but her pain persisted.  She underwent an intra-articular injection of local anesthetic into the left hip with good pain relief. The magnetic resonance imaging (MRI) scan showed a complex labral tear of the acetabulum. She underwent arthroscopic management of femoroacetabular impingement with resection of a pincer lesion and debridement of the labrum. The intraoperative findings included mild degenerative changes of the left hip with a small area of fissuring and cartilage softening of the superior weight bearing dome of the acetabulum. There was also extensive degenerative labral tearing from the 10 oclock position to the 2 oclock position of the left hip without any gross labral detachment. The pincer lesion was seen between 11 and 12:00. No cam lesion was identified. The patient has requested for reimbursement for hip surgery performed on 1/31/17. The Health Insurer has denied this request on the basis that the services at issue were investigational for treatment of this patients medical condition. Surgical treatment of symptomatic femoroacetabular impingement aims to improve symptoms and potentially delay hip osteoarthritis and prevent the need for a possible total hip arthroplasty. Hip arthroscopy and open surgical hip dislocations are the two most common surgical approaches used for this condition. The arthroscopic procedure avoids some of the complications of open surgery but both approaches result in over 75% good to excellent results.  Femoroacetabular impingement may be of the cam or pincer type, as in this case, or it may be mixed.  Surgery is recommended when the degenerative changes are mild or absent, as in this patients case, with documented failure of conservative treatment for over six months. In this case, relief of pain with an intra-articular injection of the hip joint indicated the pain source. The imaging studies further confirmed the pathology.  As such, hip surgery was better than any conventional standard treatment. As indicated in the medical literature, the surgery is known to be beneficial and is not investigational. In light of the foregoing, hip surgery performed on 1/31/17 was likely to have been of greater benefit than the standard conventional options available for treatment of the patients medical condition. 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 44-year-old female who presented to the emergency department on 10/13/19 with complaints of abdominal pain status post dirt bike accident. At the time of presentation, her vital signs were stable, with a heart rate of 112 and normal oxygen saturations on room air. The physician reviewer found that in this case, the patient was admitted in stable condition. Her pain was controlled with oral pain medications. She did not require any urgent surgery or procedures. Her vital signs were stable, and there was no evidence of hemodynamic instability or active bleeding. The inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting,
when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. Therefore, inpatient admission provided from 10/13/19 through 10/14/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The parent of a 15-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health residential treatment provided from 2/02/19 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. With regards to risk of harm, the records support a score of 2. The medical records indicate that the patient was not actively suicidal. In terms of functional status, the records support a score of 2. The patient has had some issues with level of function due to mental illness and relational issues, but overall showed appropriate daily functioning while in treatment and indicated prior school functioning was good. In terms of comorbidity, the records support a score of 2. The patient does not have a history of active serious medical issues, and her prior substance use was described to be minimal. With regards to level of stress of the recovery environment, the records support a score of 2. The patient was noted to have a strained relationship with her family and indicated some mild stress at home. In terms of level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment. With regards to resiliency and treatment history, the records support a score of 3. The patient had some outpatient mental health therapy prior to her residential admission but continued to have some symptoms of anxiety and eating disorder. She had not tried or failed intensive outpatient forms of treatment for her eating disorder. In terms of acceptance and engagement of the child, the records support a score of 2. The patient has participated in therapy. In terms of acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 17. This score correlates with intensive outpatient services. Therefore, mental health residential treatment from 2/02/19 forward was not and is not medically necessary for the treatment of this patient.