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

Summary Reviewer 

A 59-year-old male enrollee has requested authorization and coverage for spinal cord stimulator. The Health Insurer has denied this request and reported that the requested device is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the medical evidence supports the requested device in this clinical setting. Wong and colleagues concluded that the option of spinal cord stimulation should be considered after conservative therapy has failed. They pointed to large randomized control studies which showed that high frequency forms of stimulation was effective for chronic low back pain. A systematic review and meta-analysis by Taylor and colleagues concluded that spinal cord stimulation is an effective pain relieving treatment for chronic low back and leg pain with or without a prior history of back surgery.  The mean level of pain relief across 74 studies was found to be 58% at an average follow-up of 24 months. All told, the requested spinal cord stimulator is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 60-year-old male enrollee has requested reimbursement for residential treatment center services provided from 5/30/16 through 6/30/16. 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 that the residential treatment center services provided from 5/30/16 through 6/30/16 were not medically necessary for treatment of the patients medical condition. On admission the patient was not in withdrawals. There was no evidence of post-acute withdrawal symptoms. He was not a danger to self or others. Both his medical and psychiatric conditions could have been treated on an outpatient basis. He was not psychotic or manic.  There were no emotional, behavioral, cognitive, or impulsive symptoms to justify residential level of care. He presented for admission with ambivalence, and while in treatment developed a responsible drinking plan. The goal of treatment is abstinence with ongoing vigilance to prevent relapse. In this case, the patient could have been treated at a lower level of care such as intensive outpatient program (IOP) or outpatient with a concurrent 12-step program, and continuation with his psychotherapist. As such, the services at issue 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


The parent of a four-year-old male enrollee has requested reimbursement for comparative genomic hybridization performed on 1/19/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found Array-based comparative genomic hybridization has become standard of care to investigate children with developmental delay, intellectual disability, autism spectrum disorders or congenital anomalies. Until recently, it was a diagnostic test that was employed when the first-line investigation of karyotype returned normal.  Over the last eight years, it has emerged as a first-line investigation.  This test has become an important and mainstream tool in the practice of clinical genetics.  Data have now emerged showing that actionable findings from chromosomal microarray justify its use.  All told, comparative genomic hybridization performed on 1/19/15 was likely to have been superior over other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were 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


The parent of a four-year-old male enrollee has requested reimbursement for comparative genomic hybridization performed on 1/19/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found the current medical evidence supports the services at issue in this clinical setting.  The use of chromosomal microarray testing now plays a central role in the evaluation and diagnosis of children with global developmental delay, cognitive delay, and autism spectrum disorders.  Shen and colleagues noted that chromosomal microarray analysis had the highest detection rate among clinically available genetic tests for patients with ASD. Interpretation of microarray data is complicated by the presence of both novel and recurrent copy-number variants of unknown significance.  The authors reported that chromosomal microarray testing should be considered as part of the initial diagnostic evaluation of patients with ASD.  Based on the literature and current standard of practice, comparative genomic hybridization was likely to have been more beneficial than any other available evaluations.  Based upon the information set forth above, the services at issue were 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


The parent of a four-year-old male enrollee has requested reimbursement for comparative genomic hybridization performed on 1/19/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this patients case.  Chromosome microarray testing has been accepted as an appropriate first-line genetic testing for patients with autism spectrum disorders.  The testing has the potential to impact treatment, as this may allow the provider to better understand why the patient has certain medical issues. Management also deals with psychological, family, and educational needs, and may vary drastically depending on what is causing a patients issue.  Therefore, comparative genomic hybridization performed on 1/19/15 was likely to have been of greater benefit than other modalities.  Based upon the information set forth above, the services at issue were 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 




The parent of a 10-year-old male enrollee has requested reimbursement for neuropsychological testing provided on 9/6/16, 9/8/16, 9/16/16, and 9/29/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees cognitive abilities The physician reviewer found that there is a lack of support in the medical literature for the services at issue in this clinical setting. The American Academy of Pediatrics (AAP) recommend obtaining information from the teachers and parents of the student as part of the evaluation for ADHD.  The evaluation should also include the Diagnostic and Statistical Manual of Mental Disorders criteria for ADHD. The documentation provided does not indicate that these recommended assessments were performed in this case. Assessment systems such as the Vanderbilt, Connors or the Behavior Assessment System for Children (BASC), are also recommended evaluation tests for ADHD. There is a lack of medical evidence to support neuropsychological testing in this clinical setting. The primary concern, in this patients case was academic functioning and possible ADHD. As such, the services at issue are not supported by the medical literature. Therefore, the neuropsychological testing provided on 9/6/16, 9/8/16, 9/16/16, and 9/29/16 were 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 

The patient is a 20-year-old female with thyroid cancer. She underwent a total thyroidectomy with lymph node dissection on 5/31/19. The physician reviewer found that the postoperative management and concerns for total thyroidectomy patients, especially those that undergo lymph node dissections, is fairly well understood with algorithms described by major endocrine societies.  One of the concerns is hypocalcemia, which can be risk classified based on laboratory values and symptoms. This patients calcium level on postoperative day one was 7.1 mg/dL. This is very low and would qualify as a high risk or a concerning laboratory value.  Thus, it was reasonable to continue hospital care, recheck laboratory values and provide calcium supplementation. However, additional submitted records do not substantiate a second night of hospital admission. The patient was seen by the surgeon on 6/01/19 and was found to have no neurologic issues. She was not given calcium supplementation. There were also no concerns documented in the nursing notes. Since the patient was not given calcium, there is no obvious justification for further prolongation of the hospital stay. She could have received pain medication and had follow-up laboratory testing as an outpatient. The initial night of observation and symptom monitoring was medically indicated, but the patient could have been safely discharged on 6/01/19. Therefore, inpatient stay from 5/31/19 through 6/01/19 was medically necessary.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 
The patient is a 63-year-old female with psoriasis predominantly on her hands/feet-palmoplantar variety. She has requested authorization and coverage for Otezla. The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting. Based on the psoriasis treatment guidelines put forth by the American Academy of Dermatology-National Psoriasis Foundation, patients who have psoriasis affecting between 3-10% (moderate) and greater than 10% (severe) of their body surface area are candidates for phototherapy and systemic medical therapy. There are no step therapy guidelines recommended in this context, and the choice of therapy should be made at the discretion of the treating physician with attention paid to patient comorbidities. Otezla is U.S. Food and Drug Administration (FDA) approved and indicated for treatment of moderate-to-severe psoriasis and has Level A evidence to support its efficacy. Given that the patient has documented evidence of moderate-to-severe disease, it would be medically appropriate to pursue this therapy. Therefore, Otezla is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 51-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 7/13/15.  The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the breast tomosynthesis performed on 7/13/15 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Ciatto and colleagues investigated the effect of integrated two dimensional (2D) and three dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls. Based on the documentation submitted for review and medical literature cited above, the use of breast tomosynthesis 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 services at issue were 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 51-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 7/13/15.  The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that there is sufficient support in the medical literature for the services at issue in this clinical setting. The addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. Moreover, the services in dispute prevented additional magnification views. For the reasons provided, the services at issue were 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 services at issue were 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 51-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 7/13/15.  The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor. In this case, the patient presented with heterogeneously dense breast tissue. The ability to separate out superimposed tissue enables the possible delineation of an occult mass. In addition, the presence of asymmetry is also an indication for tomosynthesis. For this patient, tomosynthesis was utilized as a problem solving tool. Therefore, the breast tomosynthesis performed on 7/13/15 were 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 services at issue were 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 Overturned

Summary Reviewer 

The patient is a 35-year-old male with a lengthy history of mood/psychotic episodes and amphetamine use disorder. He was admitted to the residential treatment center due to symptoms of hallucinations, thought disorganization, racing thoughts, and pressured speech. The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is a beneficial tool in determining the appropriate level of care. In terms of risk of harm, the records support a score of 3, due to the evidence of self-neglect and inability to care for himself even in the structured residential treatment center environment due to his manic symptoms. He had a history of dangerous actions due to his manic symptoms. With regard to functional status, the records support a score of 4. This patient has been unable to complete community college courses or hold a job for longer than one month. In terms of comorbidity, the records support a score of 4 due to the presence of disabling psychiatric symptoms that interact with and impair his ability to recover from his substance use disorders. With regard to level of stress of the recovery, the records support a score of 4. He is technically homeless but mandated by probation to live in a recovery house. He has historically been unable to remain in recovery houses longer than days to weeks due to relapse of manic and psychotic symptoms. In terms of level of support of the recovery environment, the records support a score of 3.  His only natural supports would be his parents, and the patient does not reliably include them. He has not had cohesive professional supports outside of the residential treatment center. With regard to acceptance and engagement, the records support a score of 4. He has had significant treatment exposure but has been unable to achieve complete remission of optimal control of symptoms even with repeated exposure. Attempts to maintain gains attained in intensive treatment have had limited success. Therefore, the patient has a composite score of 22. In this case, the patients functional status and comorbidity were both scored as 4, which would support the residential treatment center placement. Thus, psychiatric residential center treatment provided from 12/30/19 through 1/17/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of an 11-year-old female enrollee has requested authorization and coverage for Nutropin growth hormone (GH) therapy. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees short stature and ulcerative colitis.  The physician reviewer found that according to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDs below the mean for age or more than two SDs below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient meets most of these criteria. The patients pre-treatment height was more than two SDs below the mean for age and gender. In addition, her pre-treatment growth velocity was poor and all other causes of short stature were ruled out. The patients inflammatory bowel disease has been stable and she was not receiving any steroid treatment. All told, her adult predicted height of 56-59 inches supports treatment with GH therapy based on current U.S. Food and Drug Administration (FDA) standards for treatment of idiopathic short stature. Thus, the requested Nutropin GH therapy is medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, 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 Upheld

Summary Reviewer 


The parent of a 14-year-old female enrollee has requested authorization and coverage for Nutropin AQ. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees idiopathic short stature. The physician reviewer found the requested medication is not medically necessary for treatment of the patients medical condition. The patient has idiopathic short stature, but she is more than two years post menarche, and she is past the peak of her pubertal growth spurt and her epiphyses are close to being fused. Thus, she is not a candidate for growth hormone therapy to augment height. As such, Nutropin AQ has not been established as medically necessary for treatment of the patients medical condition.  Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 19-year-old male enrollee has requested reimbursement for procedure codes 86671 x 2 and 86021 x 3 performed on 2/14/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that the services at issue were antibody tests to specific serum proteins found in some patients with inflammatory bowel disease (IBD). The diagnosis of IBD is based on endoscopic, radiologic and histopathologic criteria. For several years, there has been a search for noninvasive markers that could replace part of this diagnostic process. Antibody markers, including microbial antibodies, autoantibodies and peptide antibodies, have been explored. At present, no single marker with qualities that are satisfactory for the diagnosis and treatment of IBD have been identified. The 2018 American College of Gastroenterology guidelines make the following statement: aSerologic markers of IBD - Routine use of serologic markers of IBD to establish the diagnosis of Crohn's disease is not indicated (
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Statement).a Due to the heterogeneous nature of IBD, there has been extensive research directed toward finding immunologic markers that would assist in disease diagnosis. These studies have focused on antibodies to microbial antigens and autoantibodies. Anti-glycan antibodies are more prevalent in Crohnas disease than in ulcerative colitis but have a low sensitivity, making their use in diagnosis less helpful. In summary, antibody testing as performed in this case is not accepted in the diagnostic evaluation of patients with IBD. Endoscopic, histologic, and radiologic data assist in making the diagnosis and assessing severity. Therefore, procedure codes 86671 x 2 and 86021 x 3 performed on 2/14/20 were not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 19-year-old male enrollee has requested reimbursement for procedure codes 86671 x 2 and 86021 x 3 performed on 2/14/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that Inflammatory bowel disease (IBD) is a heterogeneous group of chronic inflammatory disorders of the gastrointestinal tract with two main distinguishable entities, Crohnas disease (CD) and ulcerative colitis (UC). IBD-unclassified (IBD-U) is a diagnosis that covers the agreya zone of diagnostic uncertainty between UC and CD. Current diagnosis of IBD relies on the clinical, endoscopic, radiological, histological and biochemical features, but this approach has shortcomings, especially in cases of overlapping symptoms of CD and UC. The need for a diagnostic tool that would improve the conventional methods in IBD diagnosis directed the search towards potential immunological markers, since an aberrant immune response against microbial or endogenous antigens in a genetically susceptible host seems to be implicated in IBD pathogenesis. The spectrum of antibodies to different microbial antigens and autoantibodies associated with IBD is rapidly expanding. However, in this patientas case, where a prior diagnosis of left-sided ulcerative colitis has already been rendered, the provideras reliance on marker testing as the final arbiter as to whether patient instead has CD is not standard of care and is not indicated in lieu of gold standard colonoscopy with biopsies. Therefore, procedure codes 86671 x 2 and 86021 x 3 performed on 2/14/20 were not likely to have been more beneficial than other available standard therapy.