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

Summary Reviewer 

A 50-year-old female enrollee has requested reimbursement for inpatient admission from 9/21/15 through 9/22/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patients symptoms had resolved prior to admission.  Her vital signs were stable at the time of admission, and the physical examination did not show signs of congestive heart failure or arrhythmia. The initial troponin level was normal. In addition, the provider documentation did not include any reasoning for assignment of the inpatient status. The treatment ordered did not include intravenous nitroglycerin or acute anticoagulation. Urgent cardiac catheterization was not recommended or performed. All of the ordered services were of the intensity that could have been safely provided at the observation level. Had any complication or problem occurred, or the subsequent testing indicated myocardial ischemia, the patient could have appropriately been converted to inpatient status at that time.  All told, inpatient admission from 9/21/15 through 9/22/15 was not medically indicated for the treatment of this patient.  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 28-year-old female enrollee has requested reimbursement for CPT code 92025 (computerized corneal topography, unilateral or bilateral, with interpretation and report) provided on 6/02/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the services at issue in this patients case.  The medical records document keratitis sicca and eyelid cellulitis.  The records indicate that the patient had ongoing ancillary testing with topography and tear osmolarity for management of dry eyes.  The current medical evidence suggests that tear osmolarity is appropriate to determine the effectiveness of dry eye treatments and progress.  However, serial corneal topography is not.  In sum, the services at issue were not likely to have been of greater benefit than other treatment options.  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 28-year-old female enrollee has requested reimbursement for CPT code 92025 (computerized corneal topography, unilateral or bilateral, with interpretation and report) provided on 6/02/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found the current medical evidence does not support the services at issue in this patients case.  Corneal topography provides a map of the cornea.  It is most often used to determine if there is any sign of ectasia.  While there can be corneal abnormalities in patients with dry eyes, the use of topography purely for the management of the dry eyes is not considered standard of care.  Likewise, since the patient could see 20/20 and the refraction showed low astigmatism, the suspicion for corneal ectasia is very low. Therefore, based on the medical records provided, the services at issue were not likely to have been of greater benefit than other treatment options.  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 28-year-old female enrollee has requested reimbursement for CPT code 92025 (computerized corneal topography, unilateral or bilateral, with interpretation and report) provided on 6/02/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the superior effectiveness of the services at issue.  Dry eye syndrome is a chronic, multi-factorial problem.  This patient has been treated with topical lubricants, medication, and punctual plugs.  Corneal topography is a method of measuring the three-dimensional shape of the cornea.  It is useful for evaluating structural abnormalities of the cornea.  While dry eye syndrome can cause interference with corneal topography, dry eye syndrome is not related to the three-dimensional shape of the cornea, and cannot be meaningfully evaluated by corneal topography.  In sum, the superior efficacy of the services at issue has not been established.  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 1


A 31-year-old female enrollee has requested authorization and coverage for exome sequence analysis (gene panel testing). The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is a lack of support for the requested services in this patients case.  The records do not demonstrate that a specific genetic condition is suspected by the requesting provider.  In the absence of a proposed diagnosis, there is insufficient evidence that this testing will change management or improve health for this patient.   In addition, given the early state of this technology, the implications of many genetic mutations are not currently known.  For these reasons, the requested services are not likely to be more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the requested services are 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 31-year-old female enrollee has requested authorization and coverage for exome sequence analysis (gene panel testing). The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that exome genetic sequencing has been shown to be beneficial for the purposes of genetic counseling and potential future disease modification. The medical evidence does not indicate therapies available for the treatment of cerebral palsy that are dependent upon the results of genetic sequencing. The general consensus with regard to genetic sequencing is that although very beneficial academically in terms of disease diagnosis, it has proven beneficial in disease management rarely. Therefore, the requested services are not likely to be of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the requested services are 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 31-year-old female enrollee has requested authorization and coverage for exome sequence analysis (gene panel testing). The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition.The physician reviewer found that patient has had a lifelong neurologic disorder without specific diagnosis and has been termed cerebral palsy, but has atypical features including episodic hypotonia, and no history of birth anoxia.  Clinical neurogenetic assessment has raised the possibility of an undiagnosed genetic disorder, for which there could be prognostic and clinical value in making a more precise diagnosis.  The medical evidence supports consideration of whole exome sequencing in the clinical diagnostic assessment of a phenotypically affected individual when the phenotype or family history data strongly implicate a genetic etiology, but the phenotype does not correspond with a specific disorder for which a genetic test targeting a specific gene is available on a clinical basis.  This patient has a phenotype that may have a genetic basis, for which specific diagnosis could yield prognostic or therapeutic advantages.  Therefore, the requested exome sequence analysis (gene panel testing) is likely to be more efficacious than other modalities for evaluating this patient.  Based upon the information set forth above, the requested services are 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 

The patient is a 55-year-old male with a long history of chronic headaches. He has seen neurologists in the past and more recently has been given the diagnosis of chronic migraine and occipital neuralgia. In a letter dated 8/23/17, the patient outlined his previous treatment with various preventive medications and stated that he is currently taking 8 to 10 Excedrin tablets per day. He reportedly responded to occipital nerve blocks in the past. The patient requested authorization and coverage for CPT codes 64722, 64772 and 64910. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The submitted documentation fails to demonstrate the medical necessity of the requested services. There are several publications regarding the use of decompression or neurolysis of the occipital nerves for the treatment of intractable headache. Many of these studies have demonstrated high success rates relative to headache reduction. However, there is a lack of studies performed using randomized studies and/or sham procedures to demonstrate efficacy greater than placebo. Accordingly, the requested services are not considered to be a standard of care and are an unproven treatment at this point.  All told, CPT codes 64722, 64772 and 64910 are not medically necessary in this patients case. Therefore, the requested services are 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 29-year-old female enrollee has requested reimbursement for allergen specific immunoglobulin G (IgG) (RAST/ELISA) for routine allergy testing performed on 3/22/19. 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 there is a lack of support for the services at issue in this clinical setting. Food-specific immunoglobulin G (IgG) level does not predict true food hypersensitivity and may actually be a marker of earlier development of food tolerance. Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods. Thus, food-specific IgG should not be used as a tool to diagnose food allergy, and the positive food should not be eliminated from the diet based upon results of these tests. The standard evaluation of food allergy consists of blood immunoglobulin E (IgE) level for foods and skin testing. IgE immunoassays are in vitro assays used to identify food-specific IgE in the serum. Immunoassays have demonstrated very high positive predictive accuracy in children for several of the major food allergens. Values have been established for egg, milk, peanut, tree nuts, and fish that correspond to a positive predictive accuracy of 95 percent. Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies. A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food. A negative skin test result indicates the absence of an IgE-mediated allergy upon subsequent challenge with a 90 to 95 percent predictive accuracy. Therefore, allergen specific immunoglobulin G (IgG) (RAST/ELISA) for routine allergy testing performed on 3/22/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 29-year-old female enrollee has requested reimbursement for allergen specific immunoglobulin G (IgG) (RAST/ELISA) for routine allergy testing performed on 3/22/19. 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 per the literature, immunoglobulin G (IgG) food sensitivity testing is not considered a clinically useful, relevant, or valid method for evaluating for food allergy, or for identifying food intolerance that may be contributing to gastrointestinal disease or any other condition. IgG and IgG subclass antibody tests for food allergy-related conditions do not have clinical relevance, are not validated and lack sufficient quality control. IgG signifies exposure to a food, not allergy to a food. IgG antibodies to food are commonly detectable in healthy individuals, independent of the presence or absence of food-related symptoms. Since a normal immune system should make IgG antibodies to foreign proteins, a positive IgG test to a food is a sign of a normal immune system. IgG4 against foods indicates that the organism has been repeatedly exposed to food components, recognized as foreign proteins by the immune system. Its presence should not be considered as a factor that induces hypersensitivity, but rather as an indicator for immunological tolerance, linked to the activity of regulatory T cells. At present, there is a lack of reliable and validated clinical tests for the diagnosis of food intolerance. IgG testing lacks both a sound scientific rationale and evidence of effectiveness. The lack of correlation between results and actual symptoms, and the risks resulting from unnecessary food avoidance, escalate the potential for harm from this test. Further, there is a lack of published clinical evidence to support the use of IgG tests to determine the need for vitamins or supplements or dietary modifications. In sum, allergen specific immunoglobulin G (IgG) (RAST/ELISA) for routine allergy testing performed on 3/22/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 29-year-old female enrollee has requested reimbursement for allergen specific immunoglobulin G (IgG) (RAST/ELISA) for routine allergy testing performed on 3/22/19. 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 multiple evidence based studies have demonstrated that immunoglobulin G (IgG) testing to foods is an unproven method of testing for food intolerances as well as food allergy. IgG antibodies are proteins produced by the immune system in response to exposure to external triggers, like pollens, foods or insect venoms. Their presence reflects exposure to these triggers, not disease that results from exposure. IgG antibodies to food are commonly detectable in healthy adult patients and children, whether food-related symptoms are present or not. There is a lack of credible evidence indicating that measuring IgG antibodies is useful for diagnosing food allergy or intolerance, or that IgG antibodies cause symptoms. The only exception is that gliadin IgG antibodies can be used to monitor the success of avoiding gluten in people with proven celiac disease. Testing for allergen specific IgG is not a recommended method of evaluating and treating a patient for suspected food allergy or food intolerance. Thus, allergen specific immunoglobulin G (IgG) (RAST/ELISA) for routine allergy testing performed on 3/22/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 56-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 10/21/15. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for treatment of the enrollees risk for breast cancer.  The physician reviewer found in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis performed on 10/21/15 was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Based upon the information set forth above, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 56-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 10/21/15. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for treatment of the enrollees risk for breast cancer.  The physician reviewer found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed on 10/21/15 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 diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 56-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 10/21/15. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for treatment of the enrollees risk for breast cancer. The physician reviewer found that Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. However, in this particular patient, there were no problems to be resolved as the patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. A routine mammogram would have been sufficient for screening purposes. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to multiple prior mammograms. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 10/21/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the diagnostic procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

An 18-year-old female enrollee has requested authorization and coverage for Pentasa 500 mg. 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 there is a lack of support for Pentasa for the treatment of this patients Crohns disease. Pentasa (mesalamine) is a 5-aminosalicylic acid. According to American College of Gastroenterology guidelines for the treatment of Crohns disease, mesalamine is not recommended for induction of or maintenance of remission. The American College of Gastroenterology guidelines state, Oral mesalamine has not consistently been demonstrated to be effective compared with placebo for induction of remission and achieving mucosal healing in patients with active Crohns disease and should not be used to treat patients with active Crohns disease (strong recommendation), even for mild disease. The guidelines also note, Oral 5-aminosalicylic acid has not been demonstrated to be effective for maintenance of medically induced remission in patients with Crohns disease, and is not recommended for long-term treatment (strong recommendation). Akobeng and colleagues and Lim and colleagues performed reviews of the use of 5-aminosalicylic acid for induction of remission and maintenance of remission in patients with Crohns disease. The authors found that mesalamine is not superior to placebo for the treatment of Crohns disease, with sufficient evidence available during maintenance therapy indicating that further study is not justified. Therefore, Pentasa 500 mg is not medically necessary for the treatment of this patient.