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

Summary Reviewer 1


A 64-year-old female enrollee has requested reimbursement for Botox injections received on 10/9/14 and 10/29/15.  The Health Insurer has denied this request indicating that the services at issue were investigational for treatment of the enrollees medical condition. The physician reviewer found the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with a history of bilateral breast cancer (at different times) and immediate breast reconstruction at two different time periods. Due to elevation of the pectoralis muscle, she underwent Botox administration for chemodenervation as a way to decrease muscle spasm and decrease postoperative pain. Although there may be some anecdotal evidence for the use of Botox when elevating the pectoralis muscle in breast reconstruction and augmentation mammoplasty to decrease muscle spasm and postoperative pain, there is insufficient evidence that Botox would be likely more beneficial than standard treatment in breast reconstruction. Therefore, without greater study with respect to Botox use in standard breast reconstruction, its use in this clinical setting was not likely to be more beneficial for treatment of the patients medical condition than other modalities. Based upon the information set forth above, the services at issue were 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


A 64-year-old female enrollee has requested reimbursement for Botox injections received on 10/9/14 and 10/29/15.  The Health Insurer has denied this request indicating that the services at issue were investigational for treatment of the enrollees medical condition. The physician reviewer found Botox injections received on 10/9/14 and 10/29/15 were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient received Botox injections to her pectoralis muscles on two occasions following breast reconstructive surgery. However, there is a lack of support in the peer reviewed medical literature that Botox injections in the pectoralis muscle post expander breast reconstruction are of proven value. Winocour and colleagues performed a literature review to determine the efficacy of Botulinum toxin A (BTX-A) injections for pain relief following placement of subpectoral tissue expanders and breast implants. They concluded that there is a paucity of high-quality published trials assessing the efficacy and safety of BTX-A in relieving post-operative pain associated with sub-pectoral placement of tissue expanders and breast implantsFurther properly conducted and reported randomized trials providing high-level evidence assessing the efficacy and safety of this practice are required. In addition, Lo and Aycock reported on a prospective, randomized, double-blinded controlled trial in 23 patients to evaluate the effects of intraoperative injection of 100 U of botulinum toxin into the pectoralis muscle on one side versus placebo on the contralateral side during immediate tissue expander reconstruction after bilateral mastectomy. The authors found that there was no statistically significant difference between preoperative to postoperative changes in the pain scores on the botulinum toxin side compared to the control side at any time point postoperatively. The authors concluded that Intraoperative injection of the pectoralis muscle with botulinum toxin is not an effective method to improve pain control in tissue expander reconstruction. All told, there is a lack of evidence in the peer-reviewed literature supporting the services at issue as likely to be more beneficial for treatment of the patients condition than any available standard therapy. Based upon the information set forth above, the services at issue were 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 64-year-old female enrollee has requested reimbursement for Botox injections received on 10/9/14 and 10/29/15.  The Health Insurer has denied this request indicating that the services at issue were investigational for treatment of the enrollees medical condition. The physician reviewer found there is support in the medical literature for the services at issue in this clinical setting. Gabriel has demonstrated in a small but hypothesis-driven randomized clinical trial that botulinum effectively addresses the sources of severe pain associated with postmastectomy reconstruction. Although there were not any notable differences in the use of narcotic, muscle relaxants, or anti-inflammatory drugs observed for the two groups in the first three days after surgery, the botulinum group used significantly fewer doses of narcotics and muscle relaxants from days seven to 45 of recovery (Gabriel).  Additionally, Gabriel found a statistically significant increase in the volume of expansion per office visit, leading to full expansion more quickly in the botulinum group than in the placebo group. Gabriels study is similar to the study by Layeeque and colleagues. In that trial, women injected with botulinum in the pectoral muscles in the time between mastectomy and tissue expander placement reported less postoperative pain and used fewer narcotics in the first 24 hours after surgery and in the final expansion period than patients who did not receive the agent. In sum, the use of Botox is an appropriate treatment for post-mastectomy breast reconstruction. For the reasons provided above, the Botox injections received on 10/9/14 and 10/29/15 were 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 services at issue were 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 1

A 35-year-old female has requested reimbursement for Oncotype Dx Colon Cancer Assay provided on 11/16/18. 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 that Adjuvant chemotherapy is of benefit to patients with stage III (node positive) colon cancer. It is much more controversial as to the usefulness of adjuvant chemotherapy in stage II colon cancer, as in this patients case. Most oncologists make this decision based on specific pathologic and clinical features in an individual that imply higher risk of recurrence. Among these features that can place a patient in a higher risk category are poorly differentiated histology, a pT4 lesion, lymphovascular invasion, or presentation with perforation/obstruction. In this case, the records do not document these features. Oncotype DX Colon Cancer Assay is a 12-gene panel that may predict the risk of recurrence in both stage III and II colon cancer. However, it is not clear if the assay can be used to predict the value of adjuvant chemotherapy in the absence of other high risk features. Therefore, Oncotype DX Colon Cancer Assay performed on 11/16/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 35-year-old female has requested reimbursement for Oncotype Dx Colon Cancer Assay provided on 11/16/18. 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 that many experts consider chemotherapy versus avoiding the toxicities of chemotherapy in such a young patient. There is a lack of consensus from expert groups as to which, if any, patients with stage II disease should receive adjuvant chemotherapy. In the study by Venook and colleagues, the recurrence score (RS) appeared to be most discerning for patients with T3 tumors that were proficient for MMR enzymes, in whom the pre-specified low-RS and high-RS groups had average five-year recurrence risks of 13 and 21 percent, respectively. Forty-four percent of patients with T3N0 pMMR tumors fell into the low-RS category and, thus, may have been spared from receiving chemotherapy. There is some support for the services at issue in this patients case. In sum, Oncotype DX Colon Cancer Assay performed on 11/16/18 was likely to have been more effective than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 35-year-old female has requested reimbursement for Oncotype Dx Colon Cancer Assay provided on 11/16/18. 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 that in this patients case, a tumor sample was submitted for Oncotype DX Colon Cancer Assay testing to help decide adjuvant chemotherapy. The Oncotype DX Colon Cancer Assay uses a reverse transcriptase-polymerase chain reaction assay for 12 genes in an algorithm that can be used to predict recurrence. The medical evidence for the test is excellent and sufficient to allow its use to estimate the risk of recurrence for stage II patients. However, current data does not support its use as a predictive marker for response to adjuvant treatment. As such, the National Comprehensive Cancer Network guidelines noted there are insufficient data to recommend use of multi-gene assay panels to determine adjuvant therapy. Thus, Oncotype DX Colon Cancer Assay performed on 11/16/18 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 51-year-old female who had a vaginal delivery in 2004 complicated by grade 4 episiotomy and Clostridium difficile on and off for six months. The patient has requested reimbursement for opium tincture 10 mg/mL provided on 2/18/20. The Health Insurer has denied this request and reported that the medication at issue was not medically necessary for the treatment of this patient. The physician reviewer found that the use of opium tincture is supported as medically necessary for the treatment of this patientas incontinence and diarrhea. American Society of Colon and Rectal Surgeons guidelines for the treatment of fecal incontinence state that medical management should be first-line therapy, and opioids result in decreased intestinal motility, decreased intestinal secretion, and increased absorption. Opiates are recommended as safe and effective for the treatment of chronic diarrhea. The patient has been stabilized on opium tincture for several years. She has attempted several medical alternatives and has undergone sacral nerve stimulator. There is sufficient support for the requested medication in this setting. Therefore, opium tincture 10 mg/mL provided on 2/18/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 48-year-old female enrollee has requested reimbursement for laparoscopic gastric sleeve (CPT 43775) performed on 12/17/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees morbid obesity. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  This patient is an adult with morbid obesity.  Per the records, her body mass index was greater than 40 kg/m2 (it was 44.9 kg/m2). The patient documented prior dietary efforts and completed a multidisciplinary evaluation that did not reveal any obvious medical, dietary or behavioral barriers to surgery. The patient met standard nationally accepted criteria for bariatric surgery.  The current medical evidence supports the services at issue in this clinical setting.  All told, laparoscopic gastric sleeve performed on 12/17/15 was medically indicated for the treatment of this patient.  Therefore, 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 45-year-old female enrollee has requested has requested reimbursement for intravenous immune globulin (IVIG) treatment provided from 3/14/16 through 4/22/16. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees chronic inflammatory demyelinating polyneuropathy (CIDP). The physician reviewer found that IVIG is U.S. Food and Drug Administration (FDA) approved for the treatment of CIDP. In this case, the patient is diagnosed with CIDP and has had a good response to IVIG treatment with improved strength and activities of daily living. The delay in administration of IVIG treatment caused the CIDP to relapse. These findings support the medical necessity for IVIG treatment. As such, IVIG treatment provided from 3/14/16 through 4/22/16 has been established as medically necessary for treatment of the patients medical condition.  Therefore, the medication at issue was 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 


An 18-year-old male enrollee has requested reimbursement for residential treatment services from 1/20/12 through 12/3/12. 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 THE residential treatment services provided from 1/20/12 through 12/3/12 were not medically necessary for treatment of the patients medical condition. The patient does not meet the medical necessity criteria for residential level of care. Despite, being treated at the residential level of care for almost a year, there was a lack of treatment notes to assess the care provided. The records fail to contain a detailed mental status exam performed on 1/20/12 at UCLA, on the day prior to admission to treatment.  At that time, the patient did not have any major concerns noted. He was given a diagnosis of polysubstance abuse and depressive disorder NOS. According to the discharge summary, the reason for referral for further treatment was because the patient showed little insight into his substance abuse. The patient had no problems with his activities of daily living. He was not homicidal or suicidal and was noted to be cooperative. The UCLA records also indicate that the patient had not received any type of substance abuse treatment. In this clinical setting, the patient could have been safely and effectively managed at a lower level of care. 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 Upheld

Summary Reviewer 1

A 46-year-old female enrollee has requested reimbursement for Botox injections provided on 7/8/15 and 11/6/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found review of the submitted documentation and relevant literature supports the use of Botox injections in this clinical setting. The patient has chronic migraine and has failed at least two medications from the same class. Moreover, the patient had reported benefit with Botox. Botox is standard therapy for treatment of chronic migraine, and has been shown to be as effective or more effective, than medications available to treat chronic migraine. In addition, Botox is U.S. Food and Drug Administration (FDA) approved for the treatment of chronic migraine. For the reasons provided, the Botox injections at issue were 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 services at issue were 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 46-year-old female enrollee has requested reimbursement for Botox injections provided on 7/8/15 and 11/6/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found there is a lack of documentation provided for review regarding the nature and character of the patients headaches. Per the current medical literature, the following drugs are known to be effective in the prophylactic treatment of headaches antiepileptic drugs, antidepressants, beta-blockers, calcium channel antagonists, serotonin antagonists, botulinum neurotoxins, [nonsteroidal anti-inflammatory drugs] NSAIDs, and others (including riboflavin, magnesium, and Petasites) (Silberstein, et al). A meta-analysis by Jackson and colleagues noted that, single trials found no differences between botulinum toxin A and amitriptyline. Based on these findings, it cannot be concluded that the Botox injections performed were more effective than other standard therapies for the patients condition.Based upon the information set forth above, the services at issue were 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 46-year-old female enrollee has requested reimbursement for Botox injections provided on 7/8/15 and 11/6/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found review of the submitted documentation and relevant literature fails to support the use of Botox injections in this clinical setting. The documentation submitted for review fails to adequately detail the patients headache symptoms to determine if she has migraine, or cervicogenic headache due to chronic neck issues. There is a lack of documentation to confirm a diagnosis of migraine or chronic migraine. Moreover, the medical literature indicates that Botox is not effective for episodic migraine or cervicogenic headache. In sum, based on the documentation submitted, the Botox injections provided on 7/8/15 and 11/6/15 were 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 services at issue were 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 27-year-old female enrollee has requested reimbursement for CPT code 63659 (percutaneous implantation of neurostimulator electrode array, epidural) provided on 11/25/19. The Health Insurer has denied this request and reported that the device at issue was not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. A case report by Lee and colleagues demonstrated efficacy for the use of spinal cord stimulation for Sphincter of Oddi dysfunction. The researchers noted a reduction in visual analog pain scores as well as a reduction in opioid consumption. In this case, the patient had chronic abdominal pain believed to be due to Sphincter of Oddi dysfunction. She had exhausted many of the standard therapeutic options, including nerve blocks, ERCP, stenting, as well as cognitive behavioral therapy and acupuncture, all with little benefit. She underwent a spinal cord stimulator trial and prior psychological screening and received significant improvement in her pain and a reduction in her opioid consumption. The medical literature has shown efficacy of spinal cord stimulation for this indication. This patient validated the efficacy of this treatment for her condition by performing a stimulator trial. Therefore, CPT code 63650 (percutaneous implantation of neurostimulator electrode array, epidural) provided on 11/25/19 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 21-year-old male enrollee has requested reimbursement for corneal collagen crosslinking performed on 9/04/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. This patient has been diagnosed with progressive keratoconus. The records noted that the patients visual acuity had been decreasing to the point where it interfered with activities of daily living. Keratoconus is caused by a structural abnormality in the collagen of the cornea, wherein the cornea becomes progressively misshapen (astigmatic) over time.  Eventually, this may develop into failure of the cornea, with intractable edema and permanent loss of vision. The classic treatment for keratoconus-induced visual decline is a corneal transplant. This procedure involves risk and the potential for significant complications. Corneal collagen crosslinking is considered to be part of the standard of care for patients with progressing keratoconus, and this involves less risk than corneal transplant. Therefore, corneal collagen crosslinking performed on 9/04/18 was likely to have been more effective than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 21-year-old male enrollee has requested reimbursement for corneal collagen crosslinking performed on 9/04/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that based on the patients vision loss and progression, corneal collagen crosslinking was the most appropriate and effective treatment available. The medical evidence has demonstrated that corneal collagen crosslinking is a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant. Furthermore, there was a lack of treatment options available to slow or halt disease progression. In sum, corneal collagen crosslinking performed on 9/04/18 was likely to have been of greater benefit than other treatment options.