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

Summary Reviewer 

The patient is a 22-year-old male with a history of idiopathic scoliosis. He has had extensive chiropractic and acupuncture care from 10/13/15-7/4/16 of at least 36 visits. His diagnoses are cervical and thoracic sprain, rib sprain, and muscle spasm. His treatment includes chiropractic manipulation, traction, and electrical stimulation, abdominal and low back exercises as well as acupuncture. He initially had severe pain but from 6/13/16 to 8/8/16, his condition was unchanged and his pain was consistently at 2/10. He had 10 acupuncture sessions from 4/29/16 to 6/4/16 and another 14 sessions from 6/13/16 to 8/8/16. The patient has requested reimbursement for the acupuncture services provided from 6/13/16 through 8/13/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. Acupuncture is not statistically different than sham acupuncture or other forms of treatment for chronic neck pain (Zhang, et al; White, et al). Thus, acupuncture is not considered medically superior to other standard available forms of treatment. The patient also did not improve during the entire time he was receiving acupuncture. Accordingly, the acupuncture treatments provided from 6/13/16 through 8/13/16 were not medically necessary for treatment of this patients idiopathic scoliosis. 

Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The representative of a 63-year-old male enrollee has requested reimbursement for air and ground ambulance services provided on 10/21/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees transition to hospice care.  The physician reviewer found based on the medical literature and the presented clinical records submitted for review, the air and ground ambulance services provided on 10/21/16 were not medically necessary for treatment of the patients medical condition. Cholangiocarcinoma is a cancer originating from the biliary tract. In this case, prior to diagnosis the patient had multiple medical co-morbidities which limited his candidacy for systemic therapy. Due to an acute presentation of sepsis, a complication of a perforated duodenal ulcer, his medical status declined rapidly after his diagnosis. His provider estimated that the patients overall prognosis was weeks to months and therefore the patient requested transfer to Texas from California so that he could spend his remaining time with family. The patient was hemodynamically stable. The patient did not require a respirator. Although his condition was considered terminal, the clinical documentation does not support air transport as medically necessary. The patients medical status did not warrant transfer and similar hospice care options were available locally. Give the lack of medical necessity for transfer to Texas, the air and ground ambulance services provided on 10/21/16 were not medically necessary for treatment of the patients medical condition. 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 40-year-old female enrollee has requested authorization and coverage for polysomnography, sleep monitoring of a patient six years or older in a sleep laboratory with breathing equipment. The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees chronic fatigue and sleep-related complaints. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patients clinical presentation is potentially suggestive of a sleep-related breathing disorder, specifically obstructive sleep apnea. Testing would be indicated to formally evaluate for obstructive sleep apnea. The clinical presentation was not otherwise suggestive of any other form of sleep disorder that is normally assessed via polysomnography. Based on the records, an attended sleep test is not the most appropriate supply or level of service which can be safely provided to the patient. The utility and validity of home sleep testing for the diagnosis of obstructive sleep apnea has been well-documented in the literature. Clinical guidelines, technology assessments, and review articles state that portable or home polysomnography may be used as an alternative to sleep-center polysomnography for the diagnosis of obstructive sleep apnea in patients with no contraindications, such as comorbid sleep disorders or major comorbid medical disorders. In this case, a home/unattended sleep test is the appropriate initial approach to evaluation of the patients complaints. If the home study is non-diagnostic for obstructive sleep apnea, then referral for attended testing could be considered. Thus, the requested polysomnography, sleep monitoring of a patient six years or older in a sleep laboratory with breathing equipment is not medically necessary for the evaluation for the evaluation of this patient. Therefore, the requested services are 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 female enrollee has requested authorization and coverage for Focalin XR. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees attention deficit hyperactivity disorder, combined type (ADHD). The physician reviewer found the record supports the medical necessity of continued coverage of Focalin XR for treatment of this patients medical condition.  The treating provider has documented that the patient has already failed three of the alternatives included in the Health Insurers prescription drug list:  Adderall XR, Concerta, and Metadate CD. It was also noted that when the patient was placed on Focalin XR, her symptoms had stabilized and were well-controlled. The use of Focalin XR is medically appropriate and consistent with the standard of care in this setting. For these reasons, the requested medication is medically necessary for treatment of the patients medical condition. For the reasons set forth above, I have determined the requested medication is 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 36-year-old female enrollee has requested reimbursement for polymerase chain reaction testing for bacterial vaginosis provided on 5/09/19. 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 there is insufficient support for vaginitis panel testing using polymerase chain reaction (PCR) technology. This testing offers no proven benefit over standard culture in symptomatic women. Furthermore, there is a lack of evidence on the clinical utility and impact of PCR testing for vaginitis. There is a lack of studies showing that this testing leads to better patient management decisions and/or better health outcomes. Studies of diagnostic accuracy alone are inadequate, especially because most symptomatic women can be diagnosed with a standard work-up and/or a trial of empiric therapy. Therefore, PCR testing for bacterial vaginosis performed on 5/09/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 36-year-old female enrollee has requested reimbursement for polymerase chain reaction testing for bacterial vaginosis provided on 5/09/19. 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 there is support for the services at issue in this clinical setting. Patients with vaginitis can be evaluated and treated with an examination, microscopy and/or cultures depending on the patients symptoms and findings. The exact process depends on the provider and the resources available at that particular office. In this case, the patient presented with a complaint of vaginal odor with no clear etiology on examination. In this setting, cultures can be helpful to determine if there is an infectious cause. It was reasonable that she was evaluated with the SureSwab, especially when no clear cause was found on examination. In sum, polymerase chain reaction (PCR) testing for bacterial vaginosis performed on 5/09/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 36-year-old female enrollee has requested reimbursement for polymerase chain reaction testing for bacterial vaginosis provided on 5/09/19. 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 Polymerase chain reaction (PCR) testing has been compared to traditional clinical testing for vaginitis. The literature supports the use of PCR testing because it has resulted in significantly higher sensitivity and negative predictive value than clinician diagnosis or in clinic testing. The test may also be superior for detecting more than one cause for vaginitis. PCR testing is a means of accurate detection that allows for appropriate treatment, and it is commonly used test in clinical practice. The records noted that the patient presented for a postpartum examination. During the postpartum period, it is especially difficult to make an accurate diagnosis of vaginal complaints. Missing an infection could lead to a serious postpartum complication. Thus, PCR testing for bacterial vaginosis performed on 5/09/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 25-year-old transgender male enrollee has requested authorization and coverage for total hysterectomy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. The Health Insurer noted that the requested services are not medically necessary because he needs to be living as male for two years and on hormones for one year before surgery. World Professional Association for Transgender Health (WPATH) has no requirements for social transition before hysterectomy. There is a one year requirement before reconstructive genital surgery, such as phalloplasty or metoidioplasty, but not for hysterectomy. Per WPATH, social transition is not required before hysterectomy. WPATH recommends one year of hormones before hysterectomy, unless this is not clinically indicated. The decision that this is clinically indicated before one year lies with the patients treatment team, which recommends the surgery. WPATH lists 12 continuous months of hormone therapy as appropriate to the patients gender goals (unless hormones are not clinically indicated for the individual). This provides flexibility for the treatment team to decide on the appropriate hormone treatment regimen before hysterectomy. WPATH noted that hysterectomy is one of the medically necessary treatments for gender dysphoria. There is sufficient support for the requested services in this clinical setting. Therefore, the requested hysterectomy 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 authorization and coverage for positron emission tomography/computed tomography (PET/CT). The Health Insurer has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees left breast carcinoma. The physician reviewer found that the role of PET/CT in the staging and surveillance of solid tumors of all types including breast is well known and accepted in the medical community. In this particular patient where there is imaging suspicion of tumor recurrence in the left internal mammary chain in a location where biopsy cannot be safely performed the role of PET/CT is ideal. If the conspicuous nodes are of high SUV they can be presumed metastatic in nature and appropriate treatment initiated. If they are of low SUV watchful waiting would be necessary. There is no other test which would be of such benefit in this particular patient. Thus, the requested PET/CT is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the requested diagnostic procedure is 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 authorization and coverage for positron emission tomography/computed tomography (PET/CT). The Health Insurer has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees left breast carcinoma. The physician reviewer found that Groheux and colleagues reported that when a recurrence is depicted or a patient is suspected of having a recurrence by using conventional imaging, PET/CT is useful to determine whether this recurrence is isolated or not, and such a determination may have a potential effect on the patients treatment. Manohar and colleagues found that PET/CT is a very sensitive and specific imaging tool in detecting and restaging recurrent breast carcinoma. It can be a very useful imaging tool for restaging locoregional recurrences, and as a one-stop shop imaging technique to confirm suspicious metastatic disease on conventional imaging and to define the total burden of disease. Thus, there is support in the literature for the use of PET/CT to follow-up this patients left internal mammary lymph nodes, suspicious for having breast carcinoma metastases. Based upon the information set forth above, I have determined the requested diagnostic procedure is 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 authorization and coverage for positron emission tomography/computed tomography (PET/CT). The Health Insurer has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees left breast carcinoma. The physician reviewer found that PET scanning involves a determination of the uptake of radioactive glucose in bodily tissues. There is abnormally increased uptake in a variety of tissues including cancer and inflammation as well as post-operative healing. There is adequate medical literature supporting the role of PET/CT in this clinical setting. This patient is at high risk for recurrence of cancer and has not been able to take hormonal therapy. Since the area of concern has been noted to be too small to appropriately biopsy, the requested PET/CT scan is likely to be more beneficial for evaluation and treatment of this patients breast cancer than any other available modality. Based upon the information set forth above, I have determined the requested diagnostic procedure is 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 Dulera 100 mcg/5 mcg inhaler. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that Asthma is a prevalent disease and management guidelines have been laid out by the collaborative Global Initiative for Asthma (GINA) since 1993. The role of combination inhalers is to better manage patients who have breakthrough symptoms on low doses inhaled steroids. There are at least five separate combination inhalers, available in both dry powder and metered doses. To date there are no comparative studies between the drugs as the compounds in them are either identical or in the same chemical family. Maspero and colleagues evaluated the long term safety and efficacy of Dulera in patients inadequately controlled by Advair. A total of 404 patients were randomized to Dulera versus Advair. They evaluated for adverse events over 52 weeks. Along with this, pulmonary function, asthma symptoms and the use of rescue medications were monitored. In all, there were no differences between the combination inhalers in rates of adverse events or the other monitored variables. In the study by  Meltzer and colleagues, they evaluated 746 subjects receiving either placebo, Dulera or the individual components over 26 weeks and the co-primary end point was timed to the first asthma deterioration and change in forced expiratory volume in 1 second (FEV1). The study found that Dulera lead to a significant reduction in the rate of asthma deterioration and time of first exacerbation along with an improvement in measured health related quality of life.  However, there appears to be no demonstrable difference between combination inhalers in regards to asthma control, in particular Dulera and Advair, one of the combination inhalers covered by the Health Insurer. Under the circumstances of this case, the patient appears to prefer the use of a metered dose inhaler to the dry powder inhaler. However, he does not have any evidence of worsened asthma control aside for clinical complaints. There are no provider notes or calls to the office, no prednisone prescriptions for exacerbations or no emergency department visits/hospital admissions. The documentation provided does not note an objective worsening of control while using effectively identical medications. As such, this patient already has the option of a metered dose inhaler (Advair HFA) that is proven to be equally efficacious as Dulera. In sum, Dulera 100 mcg/5 mcg inhaler is not medically necessary for the treatment of this patients medical condition. Therefore, for the reasons stated above, the requested medication is not medically necessary for the treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 21-year-old male enrollee has requested authorization and coverage for LINX reflux management system.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is sufficient support for the requested services in this patients case.  The Food and Drug Administration has approved the LINX reflux management system for lower esophageal sphincter augmentation.  Appropriate candidates for the procedure include patients with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm. This patient meets those specific criteria.  Per the medical evidence, the requested LINX reflux management system is likely to be superior over other 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 2


A 21-year-old male enrollee has requested authorization and coverage for LINX reflux management system.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the current medical evidence supports the requested services in this clinical setting.  LINX is a minimally invasive anti-reflux procedure that has been approved by the U.S. Food and Drug Administration.  LINX has been shown to be as effective as surgery, and is less invasive.  Additionally, LINX is potentially reversible, with less adverse effects.  In sum, the requested LINX reflux management system is likely to be more efficacious than other 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 21-year-old male enrollee has requested authorization and coverage for LINX reflux management system.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures.  Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval.  Additionally, LINX has been associated with severe dysphagia requiring endoscopic intervention. The peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication.  Based on current literature and clinical guidelines, the requested LINX reflux management system is not likely to be more efficacious than other treatment options.  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.