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

Summary Reviewer 


A 50-year-old female enrollee has requested authorization and coverage for the prescription drug Aubagio.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees multiple sclerosis. The physician reviewer found that Aubagio is one of three oral therapies now available to treat relapsing forms of multiple sclerosis.  Aubagio is a standard therapy for multiple sclerosis.  There is a lack of data indicating that the required next step of using Rebif is medically a more sound decision. There is a lack of head-to-head data showing Rebif to be more efficacious or safe than Aubagio.  Clinical experience shows that Aubagio as an oral agent does not cause injection site reactions or flu-like symptoms.  All told, Aubagio is medically indicated 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 57-year-old female enrollee has requested authorization and coverage for biliopancreatic bypass with duodenal switch (CPT code 43845) and one day inpatient admission. The Health Insurer has denied this request indicating that requested services are considered investigational for treatment of the enrollee, who has a history of morbid obesity and type 2 diabetes. The physician reviewer found that this patient is an adult with morbid obesity and a BMI of 48.9 kg/m2. The medical literature indicates that the duodenal switch (DS) is associated with significantly more risk of micronutrient and protein malnutrition. In this patients case, there are no recent dietary or psychological evaluations provided for review. Separately, there is additional risk involved and a separate psychological evaluation needs to be performed to ensure that this patient has the appropriate current level of understanding and an appropriate candidate for reoperative bariatric surgery. There is no complication of the prior sleeve gastrectomy that requires surgical treatment. There is also no record of a comprehensive updated multidisciplinary evaluation. Additionally, the record does not indicate that the additional micronutrient risks have adequately been addressed at this time. As such, biliopancreatic bypass with duodenal switch (CPT code 43845) and one day inpatient admission are not likely to be superior over the standard methods for the treatment of this patient.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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2
A 57-year-old female enrollee has requested authorization and coverage for biliopancreatic bypass with duodenal switch (CPT code 43845) and one day inpatient admission. The Health Insurer has denied this request indicating that requested services are considered investigational for treatment of the enrollee, who has a history of morbid obesity and type 2 diabetes. The physician reviewer found that there is sufficient support in the medical literature for the efficacy of the requested procedure in this clinical setting. The patient is still morbidly obese. The medical evidence appears to show that patients with diabetes of several years duration are less likely to have complete remission. The antidiabetic effects of bariatric surgery focus on both weight loss and an alteration in the gut hormone milieu with duodenal exclusion. The duodenal switch procedure excludes the duodenum. In this patient, she did lose weight with her initial surgery but her diabetes has returned, despite an almost 20 point loss in her BMI. In sum, there is support for revisional surgery in this patient who has already undergone a primary operation for weight loss. As such, the biliopancreatic bypass with duodenal switch (CPT code 43845) and one day inpatient admission are likely to be more efficacious than the available standard therapy for the treatment of this patient. 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 57-year-old female enrollee has requested authorization and coverage for biliopancreatic bypass with duodenal switch (CPT code 43845) and one day inpatient admission. The Health Insurer has denied this request indicating that requested services are considered investigational for treatment of the enrollee, who has a history of morbid obesity and type 2 diabetes.The physician reviewer found that in patients who seek surgical cure or amelioration of diabetes and obesity, several options exist.  Among these options are laparoscopic sleeve gastrectomy, which this patient had undergone.  The medical studies indicated that sleeve gastrectomy was first offered as the first part of a two-stage biliopancreatic diversion for patients who were super-obese, and are felt to be poor surgical candidates. It was then that it was realized that sleeve gastrectomy could stand on its own as a bariatric surgery. Nevertheless, there is a group of patients for whom sleeve gastrectomy fails to effect good glycemic control, as in this patients case. For these patients, the best remaining surgical solution is conversion of biliopancreatic bypass. Biliopancreatic bypass with duodenal switch is documented to be superior to medical management for treatment of weight loss. As such, biliopancreatic bypass with duodenal switch (CPT code 43845) and one day inpatient admission are likely to be more effective than the other available options for the treatment of this patient. 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer

The patient is a 57-year-old female with severe osteoporosis. As part of the work-up her endocrinologist ordered a parathyroid scan to rule out a parathyroid adenoma. The patient has requested authorization and coverage for parathyroid planar imaging. The Health Insurer has denied this request indicating that the requested diagnostic procedure is not medically necessary. The records provided for review indicate that this patient has severe osteoporosis and further evaluation for a parathyroid adenoma (primary hyperparathyroidism) is appropriate. However, the medical literature suggests that the diagnosis should be made with biochemical markers showing the combination of hypercalcemia and an elevated or inappropriately normal parathyroid hormone (PTH) level. Measured total serum calcium should be adjusted for albumin. If the corrected serum calcium is normal and PTH is elevated, serum ionized calcium should be measured, as primary hyperparathyroidism can present with an elevated ionized calcium despite a normal albumin-adjusted serum calcium (Khan, et al). The standards of care also indicate that parathyroid scan is appropriate when a decision to remove a parathyroid adenoma has been made (Khan, et al; Bilezikian, et al; Pallan, et al). Overall, parathyroid imaging is not a diagnostic procedure and is not advised unless surgical intervention is planned. The value of imaging rests with accurate identification of abnormal parathyroid tissue in order to assist in planning the appropriate parathyroid surgery (Khan, et al). In this case the diagnosis of primary hyperparathyroidism has not been established. The laboratory tests performed on 10/26/17 show normal calcium, mid-normal intact PTH level at 36 and normal ionized calcium and phosphorus. The patients 25 vitamin D and 1, 5 vitamin D levels are normal, and urinary calcium is normal. In January 2018, the patient had two normal calcium levels and intact PTH. As the patient does not have biochemical evidence of primary hyperparathyroidism, the requested parathyroid planar imaging is not medically necessary for evaluation of this patients medical condition.  Based on the foregoing discussion, the requested diagnostic procedure is 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 


A 44-year-old female enrollee has requested reimbursement for the pneumatic compressor device provided on 8/10/16. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees right lower extremity lymphedema secondary to venous insufficiency. The physician reviewer found the pneumatic compressor device provided on 8/10/16 was medically necessary for treatment of the patients medical condition. There is sufficient support in the medical literature for the device at issue in this clinical setting. Blumberg and colleagues studied the quality of life in patients with lower-extremity lymphedema treated with pneumatic compression. The authors stated that pneumatic compression has been shown to decrease the overall limb girth, as well as the number of infections and skin ulcerations.  The authors concluded that treatment with pneumatic compression improves symptom relief and reduces episodes of cellulitis and ulceration in lower-extremity lymphedema. In addition, Karaca-Mandic and colleagues found an association between use of pneumatic devices and decreased episodes of cellulitis. In this case, the patient presents with lymphedema that has been well controlled with improved quality of life with the use of the pneumatic compression. As such, the pneumatic compressor device provided to the patient was medically necessary for treatment of the patients medical condition.Therefore, the device at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 48-year-old male enrollee has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees squamous cell carcinoma. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. Compared to standard radiotherapy with photon intensity modulated radiation therapy, the benefit of proton beam therapy is with its Bragg Peak, as radiation dose is deposited more precisely on its target. This translates into a decrease in exposure of normal tissue in the low-dose to intermediate-dose range, but not in the high-dose range. Proton beam therapy is well-accepted in its ability to decrease the risk of secondary malignancy, which is largely attributable to the smaller volume of body exposed to low-dose. The benefit is greatest for larger radiation fields, such as the bilateral neck field. The risk for secondary malignancy is typically delayed at least 10 years. Thus, the potential benefit is highest in younger patients, such as this patient. Therefore, proton beam radiation therapy is likely to be of greater benefit 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 Upheld

Summary Reviewer 2

A 48-year-old male enrollee has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees squamous cell carcinoma. The physician reviewer found that there is a lack of clinical data in the medical literature to suggest that treatment with proton beam therapy 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). In this patients case, the comparative planning showed no clinically significant benefit with treatment with proton beam therapy over standard photon techniques, as all standard dose metrics are met with the photon plan. In sum, proton beam therapy is not likely to be more effective than other treatment alternatives in this patients case. 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 48-year-old male enrollee has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees squamous cell carcinoma. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. There is insufficient high-quality clinical outcomes reported in the peer-reviewed medical literature demonstrating that the requested services are safer or more effective as compared to standard of care photon radiation.  The provider has performed a photon/proton comparison plan which showed that the photon plan could be delivered safely.  There was a slight reduction in exposure to several normal tissues, but it remains unknown as to whether this would translate into a clinically meaningful benefit. Thus, proton beam therapy is not likely to be more effective 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.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 42-year-old female enrollee has requested authorization and coverage for disc fusion. 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 services at issue. Anterior lumbar interbody fusion is associated with higher fusion rates compared with posterolateral lumbar fusion in patients with degenerative changes of the lumbar spine, including those with instability.  There is moderate evidence that for lumbar degenerative disc disease without instability, a standalone anterior lumbar interbody fusion has better clinical outcomes than the anterior lumbar interbody fusion plus instrumented open posterior lumbar fusion. With regard to the type of interbody spacer used, frozen allograft is associated with lower pseudarthrosis rates compared with freeze-dried allograft. Based on these guidelines, the requested anterior lumbar interbody fusion procedure is likely to be beneficial for this patients severely symptomatic degenerative disc disease with a 4 mm protrusion at L5-S1 that did not respond to nonoperative treatment. Therefore, the requested 63077, 22558 and 22845 are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 63-year-old female enrollee has requested authorization and coverage for rizatriptan tablets 5 mg, 12 tablets per copayment every 30 days. The Health Insurer has denied this request and reported that the requested medication quantity is 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 medication quantity. This patient has been diagnosed with migraine headaches. She has tried other forms of therapy, including Topamax, gabapentin, nortriptyline, Lexapro, Wellbutrin, and Geodon. Rizatriptan is a medication that can be prescribed such that a patient may not take more than 30 mg in a 24-hour period. The dosage provided by the provider appears to be appropriate to treat three to four migraine attacks per month. This is consistent with the current standard of care. Therefore, rizatriptan tablets 5 mg, 12 tablets per copayment every 30 days is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 32-year-old female enrollee has requested authorization and coverage for Stelara 90 mg/mL every 28 days. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that Stelara has been approved by the U.S. Food and Drug Administration (FDA) for psoriatic arthritis. As per the FDA and manufacturer recommendations for the treatment of psoriatic arthritis, the recommended dose is 45 mg initially and four weeks later, followed by 45 mg every 12 weeks. For patients with co-existent moderate-to-severe plaque psoriasis weighing more than 100 kg, the recommended dose is 90 mg initially and four weeks later, followed by 90 mg every 12 weeks. In this patients case, the requested dosage exceeds what is considered standard of care and may result in morbidity. There are alternative standard of care options for the treatment of this patients psoriasis arthritis and ulcerative colitis which may be considered before stepping outside of the standard of care. Other treatment options include adding a disease-modifying antirheumatic drug, such as methotrexate, sulfasalazine or Imuran to standard dosed Stelara, or changing to an anti-tumor necrosis factor agent, such as Humira, Remicade or Simponi. Therefore, Stelara 90 mg/mL every 28 days is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 34-year-old female with a history of back pain. The patient has requested authorization and coverage for laminotomy (hemilaminectomy) L4-5. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the patient has a documented herniation at L4-5, causing persisting mass effect upon the left L5 nerve root. This has been present for a year and is slightly improved on the recent MRI. She has failed conservative treatment and continues to be symptomatic at this time. The surgical level has been confirmed with epidural steroid injections. The provider has advised surgery with decompression of the nerve root. A review of the literature indicates sufficient decompression of the nerve root canal is necessary when operating on patients with lumbar disc herniation with lumbar lateral recess stenosis. Microsurgical techniques and percutaneous techniques are common. Endoscopic techniques are also available. The provider has requested laminotomy (hemilaminectomy) at L4-5 for decompression of the nerve root. The request is supported by the medical literature. Therefore, the requested laminotomy (hemilaminectomy) L4-5 is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The guardian of a 15-year-old male enrollee has requested reimbursement for mental health inpatient treatment from 4/21/18 through 4/27/18. 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 the submitted documentation supports the services at issue in this clinical setting. Per the provided documentation, the patient remained symptomatic from 4/21/18 through 4/27/18.  He was noted to have irritable mood at times and frequently reported anxiety and agitation, which required chlorpromazine as needed.  He often required behavioral redirection from hospital staff. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth (AACAP, 2014). The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity.  Based on the patients history and clinical status as outlined above, the patient met CASII service intensity criteria for secure 24-hour service with psychiatric management (AACAP). The patients clinical status, in addition to current medical literature, support that the mental health inpatient treatment from 4/21/18 through 4/27/18 was medically necessary for the treatment of this patients medical condition (AACAP; Okado et al; Van Alphen et al).  Therefore, for the reasons stated above, the services at issue were 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 21-year-old male enrollee has requested reimbursement for applied behavioral analysis (ABA) therapy provided from 1/13/17 through 7/12/17. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the autism spectrum disorder. The physician reviewer found the ABA therapy provided from 1/13/17 through 7/12/17 was medically necessary for treatment of the patients medical condition. ABA therapy is an evidence-based treatment that has proven benefit in the behavioral treatment of autism (Smith, et al). This patient has a diagnosis of autism and continues to have significant delays. The provider indicates that the patient has highly dangerous behaviors that include running off the sidewalk onto the street, crossing the street without scanning the surroundings, and self-harm behaviors. The patient is a safety risk both at home and in the community due to his behaviors. In addition, the ABA provider has documented goals, tracking progress, and the extent of parental involvement and training indicated to meet the patients behavioral deficits. For the above reasons, the ABA therapy provided from 1/13/17 through 7/12/17 was medically necessary for treatment of the patients medical condition. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.