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

Summary Reviewer 2

A 62-year-old male enrollee has requested reimbursement for a wearable cardioverter defibrillator performed on 7/25/18, 8/25/18 and 9/25/18. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer found that in this circumstance, there is potential for recovery of left ventricular function over time with medical therapy. There was no documented indication for immediate placement of a defibrillator, such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest.  Placement of a prophylactic defibrillator is not recommended until a period of time (greater than 90 days) where continued left ventricular dysfunction is documented to persist despite appropriate treatment. A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. For example, studies assessing efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction less than or equal to 35% before ventricular function has had a chance to recover have not demonstrated improved outcome. Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explantation. Thus, the wearable cardioverter defibrillator provided on 7/25/18, 8/25/18 and 9/25/18 was not likely to have been superior over other available treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 62-year-old male enrollee has requested reimbursement for a wearable cardioverter defibrillator performed on 7/25/18, 8/25/18 and 9/25/18. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer found that the current medical evidence supports the device at issue in this clinical setting. The high risk of sudden cardiac death in patients with severe left ventricular dysfunction has led to the recommendation of implantable cardioverter defibrillators in this group of patients. Current data from multiple trials and registries have advocated the use of a wearable cardioverter defibrillator after an initial diagnosis of severe left ventricular dysfunction (ejection fraction of 35% or less). This patients ejection fraction was 20%. Given the absence of significant coronary obstructive disease at catheterization, a diagnosis of non-ischemic cardiomyopathy was made. Current guidelines recommend against placement of an implantable cardioverter defibrillator within 40 days of an acute myocardial infarction, or within 90 days of an initial diagnosis of congestive heart failure in the presence of a severely depressed ejection fraction. Therefore, a wearable cardioverter defibrillator was appropriate for a period of 90 days (dates of service 7/25/18, 8/25/18 and 9/25/18), given the patients severely depressed ejection fraction. In sum, the wearable cardioverter defibrillator provided on 7/25/18, 8/25/18 and 9/25/18 was not likely to have been of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 59-year-old female enrollee has requested authorization and coverage for Orthovisc injections. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees osteoarthrosis. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services.  There have been carefully conducted double-blinded studies which do not document any clinical effect from hyaluronan injection.  This patient has had multiple injections and with each injection and each exposure to the antigen, there is an increased risk of allergic response.  There is also risk of iatrogenic infection being introduced into the joint during the process of injection.  Rutjes and colleagues performed a recent meta-analysis of the efficacy of viscosupplementation.  The study reviewed a total of 89 trials involving 12,667 adults and concluded that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and an increased risk of serious adverse effects.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested Orthovisc injections are 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 Upheld

Summary Reviewer 


A 20-year-old female enrollee has requested reimbursement for residential treatment center (RTC) services provided from 5/15/16 through 5/17/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees eating disorder.   The physician reviewer found the records provided for review indicate this patient was not in need of 24-hour per day monitoring and supervision. In addition, she was not likely to require inpatient hospital admission if discharged from RTC level of care. The patient was above her ideal body weight, was not suicidal or psychotic, and had normal laboratory data. The patients depression could have been safely and adequately managed at a lower level of care. The patients needs could have been safely and adequately managed in a less restrictive treatment setting as well. All told, the RTC services provided from 5/15/16 through 5/17/16 were not medically necessary for treatment of this patients medical condition. 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 


A 51-year-old male enrollee has requested authorization and coverage for Xiaflex.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has severe erectile dysfunction and Peyronies disease.  The standard of care for treatment in this situation is insertion of penile implant with or without adjunct surgery for correction of curvature if needed intraoperatively.  Although Xiaflex has been shown to be effective in treatment of patient with Peyronies disease with intact sexual function, the value of Xiaflex in patients with Peyronies disease and coexisting severe erectile dysfunction has not been scientifically proven. Hence, Xiaflex is not medically indicated for the treatment of this patient.  Therefore, the requested medication is 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 parent of a 17-year-old female enrollee has requested reimbursement for intensive outpatient services provided from 3/01/18 through 6/30/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2 due to the patients history of recent ideation and hospitalization. With regards to functional status, the records support a score of 2. The patient had deterioration in expected level of functioning in relationships with peers, adults and family. In terms of comorbidity, the records support a score of 2. The patient did not have medical problems and had apparent active substance use. With regards to level of stress of the recovery environment, the records support a score of 3. The patient has problematic issues with family relationships. In terms of level of support of the recovery environment, the records support a score of 2. The patients family actively participated in treatment. However, their relationship was strained. With regards to resiliency and treatment history, the records support a score of 3 due to recent minimal progress in the intensive outpatient program. In terms of acceptance and engagement, the records support a score of 3. The patient participated, but appeared ambivalent. In terms of acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians. Thus, the patient has a composite score of 19. The score correlates with intensive outpatient services. Therefore, intensive outpatient services provided from 3/01/18 through 6/30/18 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 62-year-old male who was diagnosed with Eustachian tube dilatory dysfunction and significant middle ear pressure. The patient has requested reimbursement for endoscopic balloon dilation of the Eustachian tube performed on 12/04/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The patient has a history of ear plugging due to chronic Eustachian tube dysfunction and has been unresponsive to medical therapy. Balloon Eustachian tuboplasty has been approved by the U.S. Food and Drug Administration. This procedure has been demonstrated to be effective in a randomized clinical trial with one-year follow-up. There is sufficient support for the services at issue in this patientas case. Therefore, endoscopic balloon dilation of the Eustachian tube performed on 12/04/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 46-year-old female enrollee has requested authorization and coverage for Lamictal.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that bipolar disorder represents a severe mental disease that has poor outcomes and an exceedingly elevated suicide rate. Considering the biological nature of this life-long, recurrent illness, pharmacotherapy is a primary treatment modality for bipolar disorder.  In this case, the patient has been clinically stable for over a year on an evidence-based bipolar maintenance medication regimen endorsed by current practice guidelines and community standards. The patient has been prescribed an appropriate pharmacotherapy that is consistent with good medical practice and reasonably expected to maintain her clinical stability and prevent an exacerbation of illness. As such, Lamictal has been established as medically necessary for treatment of the patients medical condition. Therefore, 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 58-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing provided on 4/24/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. DecisionDx-Melanoma Gene Assay assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class 1 consistent with a low risk of metastasis or Class 2 suggestive of a high risk of metastasis. According to the results of analysis of this patients DecisionDx-Melanoma Gene Assay testing, the tumor was classified as Class 2A with molecular signature associated with a high risk of near term (within five years) metastatic disease, such as 77% recurrence and 80% distant metastasis free rates. Identification of the increased risk of recurrence of melanoma in this patient helped establishing appropriate follow up plan to improve the outcome in this particular patient. Thus, the DecisionDx-Melanoma Gene Assay testing provided on 4/24/17 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 58-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing provided on 4/24/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the DecisionDx-Melanoma Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma Gene Assay has shown some accuracy in thin melanomas. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. However, when an SNLB is negative there is a no accounting for hematologic spread and the Class 2 results suggest there must be another type of spread other than lymphatic which is the only type of spread accounted for by the NCCN guidelines. In this case, the patient would benefit from close follow-up clinically with ultrasound and computed tomography (CT), since he is Class 2. Thus, the DecisionDx-Melanoma Gene Assay was likely to provide additional useful information in evaluating and treating this patient. All told, the DecisionDx-Melanoma Gene Assay testing provided on 4/24/17 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 58-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing provided on 4/24/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma Gene Assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of this patients melanoma. Moreover, the DecisionDx-Melanoma Gene Assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma Gene Assay provided on 4/24/17 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 Overturned

Summary Reviewer 


A 58-year-old female enrollee has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation (PTNS) provided from 1/22/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees overactive bladder.   The physician reviewer found the records document that this patient has a diagnosis of refractory overactive bladder. She has failed multiple second- and third-line therapies and is not a candidate for certain therapies including sacral neuromodulation as noted by the provider. She has responded to PTNS. Continued treatment with PTNS is medically necessary, and a nationally accepted standard of care for this patient. The procedure for PTNS consists of the insertion of a needle above the medial malleolus into the posterior tibial nerve followed by the application of low-voltage electrical stimulation that produces sensory and motor responses. The recommended course of treatment is an initial series of 12 weekly office-based treatments followed by an individualized maintenance treatment schedule. Evidence from multiple randomized placebo-controlled trials supports the safety and clinical efficacy of PTNS. The available 12- to 36-month evidence appears consistent with maintained efficacy in relieving symptoms of overactive bladder (OAB) and urinary voiding dysfunction. The American Urological Association (AUA) and Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) guidelines support use of PTNS as third-line treatment in a carefully selected patient population with overactive bladder. Given that this patient has been treated with multiple second- and third-line therapies and is not a candidate for sacral neuromodulation, the PTNS provided from 1/22/16 forward was and is medically necessary for treatment of this patients refractory overactive bladder. Based on the foregoing discussion, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 49-year-old male enrollee has requested authorization and coverage for Simponi injections 50 mg/0.5 mL. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees rheumatoid arthritis. The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. Simponi has been recommended along with the other anti-tumor necrosis factor agents by the American College of Rheumatology for the treatment of rheumatoid arthritis. Based on a double-blind, randomized, placebo-controlled study by Bingham and colleagues, golimumab-treated patients had significantly greater improvements in the signs and symptoms of rheumatoid arthritis through week 24 when compared with placebo, with some patients experiencing a rapid onset of response as early as two weeks after initiating golimumab therapy, and efficacy was maintained through one year.  Current peer-reviewed medical studies have established the safety and efficacy of Simponi for the management of rheumatoid arthritis symptoms. As such, Simponi injections 50 mg/0.5 mL is medically necessary for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The representative of a 63-year-old male enrollee has requested reimbursement for mental health inpatient treatment from 5/23/16 through 6/23/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that there is support for a portion of the services at issue in this clinical setting. Considering the patients clinical condition and relevant history, and the potential for a complicated alcohol withdrawal syndrome, acute hospitalization represented a safe and appropriate intervention at the time of presentation. However, the record does not support the medical necessity of the setting as of 6/2/16. The patient was admitted on an alcohol detoxification protocol and was engaged in active treatment. He completed a benzodiazepine taper on 5/26/17.  The following day he was pleasant with no signs of alcohol withdrawal. The patient had his antidepressant medication, escitalopram, increased by 50% on 5/26/17 and then again to the maximum dose on 5/30/17.  He was sleeping well on a conservative dose of trazodone at nighttime.  He was adherent with his medications and had no side effects.  On 5/31/17, the patient was less tense, less confused and more relaxed.  He was eating 75 to 100% of his meals.  Although, he was isolative and labile at times, he was not disruptive on the unit.  He had no suicidality, homicidal ideation, agitated behavior or psychosis.  On 6/1/17, the patient was stable for discharge, which was planned for the next day.  However, an issue related to the power of attorney derailed the discharge.  In sum, the admission improved the patients clinical condition and more than likely prevented a more serious episode of illness.  During the course of the hospitalization, although mildly depressed in context of chronic cognitive decline, the patients acute syndrome resolved.  He was not psychotic.  He was not aggressive.  He was neither suicidal nor homicidal.  He was responding well to psychotropic medication.  He successfully completed supervised alcohol detoxification.  Continued specialty care remained indicated to capitalize on the therapeutic momentum, but there was no indication that service delivery in a less restrictive setting would have been unsafe or inadequate from 6/1/16 forward. Thus, a portion of the services at issue were medically necessary. Specifically, the mental health inpatient treatment from 5/23/16 through 6/1/16 were medically necessary, but not thereafter. Therefore, for the reasons stated above, a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Insurers denial should be partially overturned.