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

Summary Reviewer 1

The patient is a 46-year-old female with a history of right hip pain. The patients hip pain has not responded to conservative treatment in addition to revision arthroscopic labral debridement, iliopsoas bursectomy, synovectomy, lysis of adhesions, and capsular release. The patient has requested authorization and coverage for AmnioFix injection. The Health Insurer has denied this request indicating that the requested service is considered investigational. While intraarticular stem cell injections for osteoarthritis have been evaluated in clinical trials, it is not currently a standard treatment for hip osteoarthritis. In addition, there is a lack of data regarding the clinical safety including the risk of complications after surgery, compatibility of donor stem cells, and long-term effectiveness. There is an insufficient amount of clinical data demonstrating superiority of amniotic fluid injections when compared with pharmacological treatments for osteoarthritis. Given the adverse biomechanical nature of a dysplastic hip, injections of amniotic stem cells, or stem cells of any derivative, are not likely to provide any lasting relief. Thus, the requested AmnioFix injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested service is 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 2

The patient is a 46-year-old female with chronic pain at the hip joint. The patients pain has reportedly been present since 2011, treated with physical therapy, steroid injections and arthroscopic labral surgeries. A diagnosis of right labral tear was made in 2011. Arthroscopic surgery was recommended in an attempt to repair the labrum. There were multiple complications following this surgery with a total of four surgical procedures in 13 months. Pain in the hip joint continued. In 2015, a fifth surgical procedure was performed with initial improvement in symptoms followed by recurrence in symptoms. X-rays on 12/8/16 demonstrated moderate medial femoral acetabular osteoarthritis with joint space narrowing as well as moderate osteoarthritis with joint space narrowing. The patient has requested authorization and coverage for AmnioFix injection. The Health Insurer has denied this request indicating that the requested service is considered investigational. AmnioFix is described as a composite amniotic membrane substance containing growth factors unique to placental tissue. AmnioFix has been utilized in the treatment of ocular burns, conjunctival injuries, and in sheet form for wound care. AmnioFix injections have been recommended in a number of orthopedic conditions including plantar fasciitis and Achilles tendonitis. In this particular patient, anatomical changes are likely to have already occurred within the labrum and the patient has joint space narrowing such that molecular level interventions are not likely to have a positive effect. Given these findings, the requested AmnioFix injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested service is 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

The patient is a 46-year-old female with chronic right hip pain. She had undergone labral repairs, debridement, and a periacetabular osteotomy and was still unable to ambulate more than one mile. She complains of pain in the anterior groin and lateral hip described as sharp, radiating, and associated with stiffness. She also has mechanical symptoms in the hip such as catching/locking, giving way, and stiffness. On examination the gait was antalgic. Right hip flexion was 120 degrees, internal rotation was 20 degrees, external rotation was 40 degrees, and extension was 10 degrees. There was pain with range of motion. X-rays revealed medial osteoarthritis with joint space narrowing of the right hip. In 2011, it was discovered that she had severe dysplasia which caused a tear in the right labrum. She underwent a periacetabular osteotomy and repair of the labrum. Due to complications, she underwent four hip surgeries in the subsequent 13 months followed by a fifth surgery in 2015. The labrum tore again a few months later. Treatment options discussed included hip replacement and an AmnioFix injection. The patient has requested authorization and coverage for AmnioFix injection. The Health Insurer has denied this request indicating that the requested service is considered investigational. Degenerative joint and tendon injuries remain difficult to treat in patients with few effective conservative treatment options. Regenerative approaches aim to promote the inherent healing capacity of injured tissues. Micronized dehydrated human amnion/chorion membrane (dHACM) injection is an emerging regenerative option with promising preclinical and clinical results. Gellhorn and Han reported that dHACM was clinically effective in reducing pain and improving function in the majority of adults enrolled in the study. Zelen and colleagues reported there are limited data available regarding most amniotic membrane-based products. However, there is substantial preclinical and clinical evidence supporting the rationale and effectiveness of dHACM allograft as a treatment modality. As such, a trial of micronized dehydrated human amnion/chorion membrane injection (AmnioFix) is a good option for this patient which is likely to be more effective than any other standard treatment for her medical condition.  Based upon the information set forth above, the requested service is 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 Overturned

Summary Reviewer 


A 54-year-old male enrollee has requested authorization and coverage for Sovaldi and Olysio. The Health Insurer has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found that according to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. Per the guidelines, patients with cirrhosis are high priority for treatment. After failure of NS5A inhibitors such as Harvoni, AASLD/IDSA guidelines state that patients who are high priority for treatment (such as this patient) should undergo testing for resistance-associated variants and retreatment when possible. When resistance to NS5A inhibitors is present and NS3 resistance is absent, as in this case, the recommended therapy is Sovaldi and Olysio with ribavirin for 24 weeks based on the resistance testing profile (Lawitz, et al; Buti, et al).  For these reasons, the requested treatment with Sovaldi and Olysio  is supported as medically necessary for the treatment of this patients hepatitis C infection. Therefore, based on the reasons stated above, the requested medications are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 34-year-old male has requested reimbursement for polymerase chain reaction (PCR) testing performed on 8/03/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the current medical evidence does not support the services at issue in this clinical setting. The patient likely had a viral exanthem. He is treated with an antibiotic for presumed strep infection. The records do not support a clinical reason for ordering PCR testing. The treatment would not change based on this testing. Therefore, PCR testing performed on 8/03/17 was not likely to have been superior over other methods of evaluating this patient. Based upon the information set forth above, the services at issue were 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 34-year-old male has requested reimbursement for polymerase chain reaction (PCR) testing performed on 8/03/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the EBV infection can be suspected with an appropriate clinical presentation of sore throat, fever, and malaise with enlarged lymph nodes on examination. The recommended laboratory testing for a case of EBV infection causing mononucleosis is a complete blood count and liver enzymes and heterophile antibodies. In this case, the patient presented with a recent pharyngitis and rash after treatment with an antibiotic. At the time of presentation, the patient noted improved symptoms with treatment of the antibiotic, and there was no fever or enlarged lymph nodes on examination. The concern was for EBV infection causing mononucleosis. The testing with a complete blood count was unremarkable, and the appropriate test for EBV infection would have been heterophile antibody testing.  The requested PCR would not be more beneficial in this case than the recommended testing, heterophile antibody testing. In sum, PCR testing performed on 8/03/17 was not likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 34-year-old male has requested reimbursement for polymerase chain reaction (PCR) testing performed on 8/03/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the patient did not have clinical evidence of infectious mononucleosis. The evaluation on 8/03/17 suggests a viral pharyngitis. He had already been given an extended spectrum penicillin antibiotic. The rash was not suggestive of mononucleosis. This disease may cause a macular rash, but it does not produce a pustular eruption.  Importantly, the patient did not have a lymphocytosis. Additionally, PCR testing on blood is not a test used to make a diagnosis of monoucleosis.  The tests sole use is in highly immunocompromised individuals who may have a viremic illness. Thus, PCR testing performed on 8/03/17 was not likely to have been more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were 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 Upheld

Summary Reviewer 


A 30-year-old male enrollee has requested reimbursement for L0637 (lumbar support brace) provided on 1/7/15. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees low back pain. The physician reviewer found that based on the clinical records submitted for review, the L0637 (lumbar support brace) provided on 1/7/15 was not medically necessary for treatment of the patients medical condition. The office visit dated 1/7/15 does not provide sufficient rationale supporting the clinical indication for the lumbar support brace provided. On 1/7/16, the office visit indicates that the patient reports to improving 10% since the onset. Given that the patient had improved and in the absence of clinical rationale supporting the device, the L0637 (lumbar support brace) provided on 1/7/15 was not medically necessary for treatment of the patients medical condition. Therefore, the device at issue was 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 


A 69-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the pelvis without contrast material, followed by contrast material and further sequences (CPT 72197). The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees rising prostate specific antigen (PSA) levels.  The physician reviewer found that the American Urological Association (AUA) guidelines do not advocate the use of multiparametric MRI as a routine screening tool for prostate cancer. However, the current medical literature has demonstrated that in certain patients, multiparametric MRI offers an advantage not afforded by transrectal ultrasound (TRUS) guided biopsy. Such is the case for this patient. The patients steady rise of PSA with tripling of the value over three years is a concern for prostate cancer. The literature reports that there can be significant risk with TRUS guided biopsy with significant false negatives since the cores are randomly obtained. The use of multiparametric MRI allows the stratification of risk for aggressive tumor and compares more favorably to random biopsies. This patient is at risk for prostate cancer due to steadily rising PSA. Thus, for this particular patient, the requested multiparametric MRI is medically necessary for further evaluation of his medical condition. Based on the foregoing discussion, the requested services are medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 31-year-old female enrollee has requested reimbursement for inpatient mental health services provided from 11/7/17 to 12/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees eating disorder and depression. The physician reviewer found that applying the level of care utilization system (LOCUS) criteria, the inpatient mental health services provided from 11/7/17 to 12/6/17 were not medically necessary for treatment of this patients behavioral health issues. The patient presented with significant risk of harm (score 3) with a history of a suicide attempt at age 15 by attempting to overdose on Advil. The patient also has a history of self-cutting from the ages of 14-19 years old. On 11/7/17 and several days prior, the patient had intermittent passive suicidal thoughts. The patient demonstrated moderate functional impairment (score 3) and due to her symptoms, the patient was unable to fulfill her responsibilities in her work. The patient showed significant co-morbidity (score 3) with history of bipolar II, cluster B traits, and bingeing, purging, and restricting behaviors. The patient did not have substance abuse problems. The patients recovery environment is mildly stressful (score 2) as she demonstrated distress while she was traveling in Paris due to isolation. The patients recovery environment was supportive (score 2) and she demonstrated moderate response to prior treatment (score 3). The patient demonstrated positive engagement and recovery (score 2) as she was described as attentive and engaged during treatment. The patient had a positive attitude toward recovery and treatment. These findings give the patient a composite score of 18, which is consistent with intensive outpatient program (IOP) level of care. The patient continued to require treatment for her of bipolar II, cluster B traits, and bingeing, purging, and restricting behaviors, but this could have been safely and effectively provided in a less restrictive environment. Therefore, the services at issue were not medically necessary. 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 Overturned

Summary Reviewer 


A 45-year-old female enrollee has requested authorization and coverage for arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees back pain. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this clinical setting. This patient presents with persistent severe right greater than left SI joint pain. Functional difficulty was documented in sitting tolerance, activities of daily living, and work ability. She was status post circumferential L3-S1 instrumented fusion in May 2014 with initial positive surgical benefit allowing return to work. She reported progressively worsening bilateral buttocks pain. There was evidence of long-term conservative treatment including medications, activity modification, SI joint injections, sacroiliac radiofrequency ablation, and physical therapy without sustained improvement. Clinical examination findings have documented SI joint tenderness with four positive sacroiliac provocative testing. There was radiographic evidence of bilateral sacroiliac arthropathy, right greater than left, consistent with adjacent segment degeneration. Multiple SI joint injections have been documented with 100% relief on the day of injection and diminishing response over time. In this patients case, the current evidence based medical guideline and peer-reviewed surgical indications for SI joint fusion have been met. In sum, arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance is medically necessary for treatment of this patient. Therefore, for the reasons stated above, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 62-year-old male enrollee has requested reimbursement for testing for liver disease provided on 6/11/19. 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 FibroTest and FibroSure are identical proprietary tests marketed under different names in Europe and America, respectively. ActiTest is a modification of FibroTest. The tests have primarily been studied in patients with hepatitis B and C. FibroTest involves assessment of alpha-2-macroglobulin, alpha-2-globulin, gamma globulin, apolipoprotein A1, and total bilirubin. It also takes into account the patients age and sex. Results from the individual assays are combined and are used to classify patients having mild fibrosis (F0 to F1), significant fibrosis (F2 to F4), or an indeterminate stage of fibrosis. The sensitivity for detection of significant fibrosis is approximately 60 to 75 percent, and the specificity is approximately 80 to 90 percent. In clinical practice, the services at issue are used routinely in patients with hepatitis B. Therefore, testing for liver disease (FibroTest-ActiTest/HCV-FibroSure) provided on 6/11/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 62-year-old male enrollee has requested reimbursement for testing for liver disease provided on 6/11/19. 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 in chronic hepatitis B patients, such as this patient, identification of cirrhosis defines treatment endpoints and options. Non-invasive studies, such as FibroTest, are typically applicable to the hepatitis C population, and those with other chronic liver conditions. Relative to FibroTest itself, Jieanu and colleagues opined Fibrotest is a patented formula which involves several parameters: total bilirubin, haptoglobin, gamma glutamyl transpeptidase, a2-microglobulin apolipoprotein-A, age and gender, with the results correlated with the METAVIR score. This evaluation is the most used indirect marker showing excellent results in a meta-analysis in chronic hepatitis C (CHC).  Supporting this contention, Parikh and colleagues concluded that FibroTest is useful in ruling out chronic hepatitis B-related cirrhosis. Thus, while liver biopsy remains the gold standard for assessment of hepatic fibrosis, the assay under review in this case provides ready assessment of progression to cirrhosis without the inherent risks of invasive testing. In sum, testing for liver disease (FibroTest-ActiTest/HCV-FibroSure) provided on 6/11/19 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 62-year-old male enrollee has requested reimbursement for testing for liver disease provided on 6/11/19. 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 FibroTest has demonstrated that it reliably determines the presence of advanced fibrosis and cirrhosis in a variety of liver diseases which can cause continuously advancing liver injury, including hepatitis B. It is important to identify cirrhosis early, as it requires specific and routine monitoring, such as ultrasound every six months, to prevent complications. Liver biopsy, by contrast, is invasive, with risks including bleeding and bile duct injury. It is subject to interoperator variability during interpretation and is also subject to sampling error. Thus, testing for liver disease (FibroTest-ActiTest/HCV-FibroSure) provided on 6/11/19 was likely to have been more beneficial than other methods of evaluating this patient.