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

Summary Reviewer 2

[INSERT FIRST TWO SENTENCES FROM SUMMARY REVIEW DETERMINATION] The physician reviewer found that the American Society of Colon and Rectal Surgeons guideline for the management of hemorrhoids describes Doppler guided hemorrhoidectomy as an effective surgical intervention for patients that have failed medical management and office-based procedures (Davis, et al). In the peer-reviewed medical literature, Ratto and colleagues performed a multicenter trial of transarterial hemorrhoidal dearterialization performed in 803 patients with symptomatic grade II, III, or IV hemorrhoids. The authors noted that the overall success rate was 91%, with recurrence in 9%. Based on these results, the authors concluded that transarterial hemorrhoidal dearterialization is a safe and effective treatment for patients with symptomatic grade II, III, or IV hemorrhoids. As this patients grade III internal hemorrhoids have not been responsive to conservative medical management or rubber band ligation, the Doppler guided transanal hemorrhoidal dearterialization provided on 11/20/17 was 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 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

[INSERT FIRST TWO SENTENCES FROM SUMMARY REVIEW DETERMINATION] The physician reviewer found that Ttansanal hemorrhoidal dearterialization is an option for the treatment of grade II and III internal hemorrhoids in patients that have failed non operative treatment. However, randomized trials have failed to consistently demonstrate significant benefits of this therapy alternative surgical procedures. Although there is data to show that transanal hemorrhoidal dearterialization is a safe and effective method of surgically treating hemorrhoids, there is a lack of clinical trials reporting benefits of transanal hemorrhoidal dearterialization over standard treatment options. Thus, the Doppler guided transanal hemorrhoidal dearterialization provided on 11/20/17 was 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 

A 61-year-old male enrollee has requested reimbursement for proton beam radiation therapy provided from 6/26/19 through 8/29/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that currently, there is a lack of clinical data in the medical literature to suggest that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for tumors of the head and neck area. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy (IMRT). A comparative analysis by Sio and colleagues found no significant difference in symptom burden in the acute and chronic phases of treatment with proton therapy compared to photon therapy for head and neck cancer. The American Society of Radiation Oncology (ASTRO) emerging technology committee report on proton therapy specifically states that there is insufficient data to recommend proton beam therapy for routine head and neck radiation therapy outside of clinical trials. The comparative plan was reviewed in detail and shows that standard treatment methods are sufficient to treat this patient and that the proton therapy plan does not result in a meaningful clinical difference despite having lower dose to one of the parotid glands. Consensus group guidelines do not support the use of proton therapy in this setting. There is a lack of level I evidence to support the use of proton therapy for the treatment of head and neck cancer. Therefore, proton beam radiation therapy provided from 6/26/19 through 8/29/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma test performed on 10/19/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. There is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Therefore, DecisionDx-Melanoma testing provided 10/19/18 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 33-year-old female enrollee has requested reimbursement for exome sequence analysis (81415) provided on 8/15/19. 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 Society for Maternal-Fetal Medicine indicates that routine use of prenatal sequencing as a diagnostic test is not currently supported due to insufficient validation data and knowledge about its benefits and pitfalls. Although the technology is promising in genetic evaluation of an anomalous fetus, many challenges remain for the routine clinical use of exome sequencing. Interpreting results from exome sequencing is a very lengthy process, and is challenging due to reliance on phenotypic data that may be incomplete. Additionally, there are many counseling and ethical issues related to prenatal exome sequencing, including determining when to report secondary or incidental findings, the ongoing need for reanalysis of results, and the challenges of interpreting results in meaningful ways for patients. Therefore, given the complexities involved in interpretation of results, timeliness of results, and patient/family counseling, the decision to proceed with this type of testing should be made in consultation with a provider specializing in genetic testing, such as a certified genetic counselor or medical geneticist and is currently not the standard of care or medically necessary as in this case. Thus, CPT 81415 (exome sequence analysis) performed on 8/15/19 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 13-year-old male who has been evaluated by a pediatric endocrinologist since 2014. In 2014, he displayed normal growth velocity and delayed bone age.  The patients parent has requested authorization and coverage for Humatrope injection 24 mg. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the U.S. Food and Drug Administration (FDA) defines idiopathic short statute as height z-score below 2.25 standard deviations without apparent etiology after thorough professional evaluation. This patient does not meet these criteria. His growth velocity and provoked growth hormone release are normal. His growth pattern and predicted adult height are consistent with his familial pattern. His predicted adult height of 66.5-67 is within the normal range for adult men in North America. This patient not meet clinical criteria for an FDA-approved indication for somatotropin.  Familial short stature with constitutional delay of growth and development is the most appropriate diagnosis as documented by the treating pediatric endocrinologist. Therefore, Humatrope injection 24 mg is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 19-year-old female enrollee has requested reimbursement for substance use partial hospitalization services provided form 10/08/18 through 10/11/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. With regards to functional status, the records support a score of 2 due to an overall good functional level with appropriate activities of daily living. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability with stable psychiatric symptoms. With regards to level of stress of the recovery environment, the records support a score of 2 due to no mention of a stressful recovery environment. In terms of level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources. With regards to treatment and recovery history, the records support a score of 2 due to success in the treatment program with a good level of cooperation and stabilization of symptoms. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into her need for treatment. Thus, the patient has a composite score of 13. This score correlates with low intensity, community-based services. This patients presentation did not meet criteria for partial hospitalization program level of care. Therefore, substance use partial hospitalization that was provided from 10/08/18 through 10/11/18 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 34-year-old female enrollee has requested authorization and coverage for Sovaldi and RibaPak. The Health Insurer has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) all patients with chronic HCV regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions. Per the AASLD/IDSA guidelines, non-cirrhotic genotype 2b patients should be treated with Sovaldi and ribavirin for 12 weeks. This is based on multiple randomized controlled trials and Sovaldi is U.S. Food and Drug Administration (FDA) approved for patients with chronic hepatitis C genotype 2 regardless of fibrosis stage (Zeuzem, et al; Lawitz, et al; Jacobson, et al). AASLD guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and RibaPak is supported as medically necessary for the treatment of this patients hepatitis C infection. For the reasons provided, the requested medications are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 54-year-old female enrollee requested authorization and coverage for arthrodesis sacroiliac joint percutaneous. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees bilateral sacroiliitis. The physician reviewer found Evidence based medical guidelines support SI joint fusion (either open or percutaneous) on a case by case basis as a last line of therapy for the following conditions, with ongoing symptoms, corroborating physical examination findings and imaging, and after failure of non-operative treatment: SI joint infection, tumor, disabling pain due to sacroiliitis due to spondyloarthropathy, sacroiliac pain due to severe traumatic injury, and in conjunction with multisegmental spinal constructs. The International Society for Advancement of Spine Surgery (ISASS) policy statement for minimally invasive sacroiliac joint fusion provides specific indications for surgery. The ISASS criteria include significant sacroiliac joint pain or significant limitations in activities of daily living because of sacroiliac joint pain; sacroiliac joint pain confirmed by at least three positive sacroiliac joint provocative tests; confirmation of the sacroiliac joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular sacroiliac joint block in the immediate post-injection period; failure to respond to at least six months of non-surgical treatment including medications, rest, physical therapy, and sacroiliac joint steroid injection or rhizotomy; and, additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been clearly considered, investigated and ruled-out. This patient presents with persistent and unremitting bilateral SI joint pain, right greater than left. Significant functional difficulty has been documented in activities of daily living. She reported an onset of pain relative to a fall from counter height onto her buttocks in August 2015. There is evidence of long term conservative treatment including medications, activity modification, SI joint injections, and physical therapy without sustained improvement. Clinical examination findings have documented bilateral SI joint tenderness with at least three positive sacroiliac provocative tests. Bilateral SI joint injections have been documented with 75-80% short term pain relief. In this patients case, current evidence based medical guideline and peer-reviewed surgical indications for SI joint fusion have been met. All told, arthrodesis sacroiliac joint percutaneous is 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 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 54-year-old female enrollee requested authorization and coverage for arthrodesis sacroiliac joint percutaneous. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees bilateral sacroiliitis. The physician reviewer found A study by Polly and colleagues involved a randomized controlled trial of minimally invasive sacroiliac joint fusion using triangular titanium implants compared to nonsurgical treatment at 12 months. A total of 148 patients with sacroiliac joint dysfunction were randomly assigned to minimally invasive sacroiliac joint fusion with triangular titanium implants or nonsurgical treatment.  The conclusion was that this level one study showed that minimally invasive sacroiliac joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with sacroiliac joint dysfunction caused by degenerative sacroiliitis or sacroiliac joint disruptions.  Pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment. In another recent article in the International Journal of Spine Surgery in March 2015, sacroiliac joint fusion using triangular titanium implants was compared to nonsurgical management at six months with a prospective randomized controlled trial.  The conclusions were that six month follow up from this level one study showed that minimally invasive sacroiliac joint fusion using triangular titanium implants was more effective than nonsurgical management in relieving pain, improving function, and improving quality of life in patients with sacroiliac joint dysfunction due to degenerative sacroiliitis or sacroiliac joint disruptions.  Based upon a review of the recent literature, the requested minimally invasive sacroiliac joint fusion is appropriate in this clinical setting. There are enough studies in the literature to prove that the procedure is effective as a treatment option for patients diagnosed with bilateral sacroiliitis. As such, bilateral minimally invasive arthrodesis sacroiliac joint percutaneous is likely to be more effective for treatment of the patients medical condition than any available standard modality.
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 54-year-old female enrollee requested authorization and coverage for arthrodesis sacroiliac joint percutaneous. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees bilateral sacroiliitis. The physician reviewer found There is a growing body of literature looking at sacroiliac fusion and minimally invasive SI fusion in particular. This included randomized controlled trials, a few systematic reviews, and multiple other peer-reviewed studies. However, there continues to be concerns about the quality of the literature available and inherent biases present with many of the studies being industry sponsored and a lack of high level evidence and homogeneity of patient populations and outcome measurements.  Furthermore, there are still concerns with symptom overlap from SI joint and other closely related pathology.  Based on the patients generalized pain profile as outlined in her subjective pain complaints and pain diagram, as well as the underlying diagnoses of chronic lower back pain and fibromyalgia, there is no clear evidence supporting that the requested services will likely be more beneficial than the available standard therapy for treatment of this patients medical condition. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 16-year-old female with posttraumatic stress disorder (PTSD), as well as alcohol, cannabis, sedative/hypnotic/anxiolytic, psilocybin, and LSD use disorders, as well as a history of self-harm. The patientas parent has requested reimbursement and prospective authorization and coverage for intensive outpatient mental health treatment provided from 4/24/20 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 this patient. The physician reviewer found that The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. In terms of risk of harm, the records support a score of 3. The records noted significant risk of harm, due to continued self-harm, even after months of IOP treatment. With regard to functional status, the records support a score of 3. The patient had moderate functional impairment, due to interpersonal conflict with parents and struggles to focus during online school.  In terms of comorbidity, the records support a score of 3. The patient had significant comorbidity, due to recent substance use as well as post-traumatic stress disorder, with decline in substance use while participating in the increased structure of the IOP. With regard to recovery environment, the records support a score of 2. The patient had a mildly stressful environment, due to social isolation of shelter-in place, conflict with parents, struggles with school, and potential exposure to the sisteras substance use in the home. Environmental support is scored at 2 due to the parentsa participation in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient was able to maintain abstinence from substance use while at the IOP. However, she has continued to struggle with trauma-related symptoms and self-harm. In terms of treatment acceptance and engagement, the records support a score of 2. The patient participated in treatment, with some struggles in fully implementing the strategies learned. Thus, the total CALOCUS score is 18. In this case, the recommended level of care is level three: high-intensity community-based services. This is consistent with the IOP level of care that patient has been receiving. Therefore, intensive outpatient mental health treatment provided from 4/24/20 forward was and is medically necessary for the treatment of this patient.