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

Summary Reviewer 1

A 31-year-old female enrollee has requested reimbursement for osteochondral knee autograft CPT code 27416 performed on 3/7/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee who had injured her left knee.The physician reviewer found there is sufficient support in the medical literature for the efficacy of the services at issue in this clinical setting. Current evidence based medical literature recommends osteochondral autograft transplant surgery (OATS) when specific criteria have been met. Indications for surgery include conservative treatment (medications or physical therapy) plus subjective clinical findings of joint pain and swelling. Objective clinical findings include failure of previous subchondral drilling or microfracture, larger full thickness chondral defects that measure less than 3 cm2 on the weight bearing portion of the medial or lateral femoral condyle, intact and fully functional menisci and ligaments, normal knee alignment, normal joint space, and body mass index (BMI) less than 35. Additionally, there must be imaging evidence of chondral defect on the weight bearing portion of the medial or lateral femoral condyle. Gudas and colleagues concluded that the OAT technique for articular cartilage defect or osteochondral defect repair in the athletic population allows for a higher rate of return to and maintenance of sports at the preinjury level compared with microfracture. This patient presented with left knee pain and swelling that was significantly limiting her normal daily activities. The record indicates that her BMI was less than 35. Clinical examination findings were consistent with imaging evidence of a full thickness chondral defect on the lateral femoral condyle measuring less than 1 cm2. There was also imaging evidence of a small posterior tibial plateau tibial defect and loose bodies. The orthopedic surgeon reported that there was no full thickness or kissing lesion present on the tibia corresponding to the femoral lesion. Reasonable conservative treatment, including ice, NSAIDs, and activity modification, and failure were documented. As such, current peer reviewed medical literature supports the use of OATS for this patient over other procedures for return to and maintenance of sports at a pre-injury level. Therefore, osteochondral knee autograft, CPT code 27416 performed on 3/7/17 was likely to have been more beneficial for treatment of this 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 Overturned

Summary Reviewer 2

A 31-year-old female enrollee has requested reimbursement for osteochondral knee autograft CPT code 27416 performed on 3/7/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee who had injured her left knee. The physician reviewer found that cartilage grafts and/or transplantations remain controversial. Systematic reviews have yet to demonstrate the superiority of OATS over the more standard procedures in this clinical setting. The aim of the OATS technique is to slow down the development of osteoarthritis. There is some scientific evidence of effectiveness for patients with a singular, traumatically caused grade III or IV femoral condyle deficit who are under 40 years of age and have an active lifestyle. However, the available evidence from individually published case series is not sufficient to permit definitive conclusions concerning the effectiveness of the OATS procedure. Therefore, osteochondral knee autograft, CPT code 27416 performed on 3/7/17 was not likely to have been superior over the other treatment options available to this patient. 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 Overturned

Summary Reviewer 3

A 31-year-old female enrollee has requested reimbursement for osteochondral knee autograft CPT code 27416 performed on 3/7/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee who had injured her left knee. The physician reviewer found there is evidence of the effectiveness of the osteochondral autologous transfer for patients with a single, traumatically caused grade III or IV femoral condyle deficit who are under 40 years of age and have an active lifestyle. Osteochondral autologous transfer (OAT) technique is a method used to slow down the development of osteoarthritis. In the article by Werner and colleagues, 152 OAT procedures were  reviewed, of which 20 competitive athletes met inclusion and exclusion criteria. All patients underwent an accelerated rehabilitation program after their procedure. Return to sport was determined for all athletes. All athletes were able to return to sport at their previous levels and reported that they were satisfied or very satisfied with their surgical outcome and ability to return to sport. The medical literature shows promising results of this technique at medium to long term follow up. In this patients case, she had a single full thickness articular cartilage lesion in the weight bearing zone. According to the medical literature, this patient was likely to have benefitted from this procedure when compared to other methods of therapy. Accordingly, osteochondral knee autograft, CPT code 27416 performed on 3/7/17 was likely to have been more efficacious for the treatment of this patients medical condition than any other available treatment options. 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 39-year-old male enrollee has requested authorization and coverage for the LINX procedure.  The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found the LINX procedure is not likely to be more effective for this patient than other available treatment options. There is a lack of documentation provided that demonstrates the patient is not a candidate for a Nissen fundoplication, which is the gold standard surgical treatment for GERD. Based upon a prospective study by Lipham and colleagues of 44 patients who underwent placement of the LINX System most patients at up to four years of observation experienced improved quality of life and complete cessation of the use of proton pump inhibitors. However, the studies to date have not had a control arm and each patient is used as their own control. The durability of the procedure is also unknown. Although early studies in regards to LINX are encouraging, the studies to date are primarily less than five years. Because of the lack of controlled data and long-term studies, the requested LINX procedure 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 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 2

A 39-year-old male enrollee has requested authorization and coverage for the LINX procedure.  The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found the appropriate patient selection is crucial before anti-reflux procedures. In prelude to surgical intervention for GERD, it is critical to document the presence of abnormal distal esophageal acid exposure, especially when anti-reflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and workup of GERD, and no single test alone can provide the entire clinical picture. Results of testing are combined to document the presence and extent of the disease and assist in planning the operative approach. Currently, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for anti-reflux surgery (Jobe, et al). In this case, the patient has undergone only some of this pre-operative assessment. Moreover, this patient presents with GERD with finding of short-segment Barretts esophagus and implantation of LINX has not been studied in patients with Barrett's esophagus (USC Keck School of Medicine). Therefore, the LINX procedure 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 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 39-year-old male enrollee has requested authorization and coverage for the LINX procedure.  The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found LINX Reflux Management System is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Lipham and colleagues performed a multicenter, prospective, single-arm study that included 44 patients who underwent a laparoscopic surgical procedure for placement of the LINX System around the gastroesophageal junction. The authors demonstrated efficacy up to four years in the reduction of the amount of pathologic esophageal acid exposure. The authors concluded that the magnetic device decreased exposure to esophageal acid, improved reflux symptoms, and allowed cessation of proton-pump inhibitors in the majority of patients. Additionally, the requested procedure is approved by the U.S. Food and Drug Administration (FDA). Based on the support in the medical literature cited above, the requested procedure is likely to more beneficial for treatment of the patients medical condition than any available standard therapy. 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 Overturned

Summary Reviewer 

A 20-year-old female enrollee has requested reimbursement for unlisted procedure of the skin, mucous membrane and subcutaneous tissue (17999) performed on 11/26/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the current medical evidence supports the services at issue in this clinical setting. This patient has documented gender dysphoria. His gender dysphoria included dysphoria about breasts. Chest surgery in a transgender male has been shown to be an effective treatment for gender dysphoria. The World Professional Association for Transgender Health (WPATH) noted that sex reassignment surgery is effective and medically necessary. Per WPATH, criteria for mastectomy and creation of a male chest in transgender male patients includes persistent gender dysphoria, capacity for informed consent, age of majority, and medically and psychiatrically stable for surgery. This patient meets these criteria. Therefore, the unlisted procedure of the skin, mucous membrane and subcutaneous tissue (17999) performed on 11/26/18 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 64-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 2/07/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees melanoma. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines indicate while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of this testing were unlikely to have altered treatment and surveillance recommendations. Thus, DecisionDx-Melanoma testing performed on 2/07/18 was not medically necessary for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 62-year-old female enrollee has requested reimbursement for Prolia injection performed on 8/27/15.  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 osteoporosis is an increasingly widespread condition, and fractures are the most dangerous aspect of osteoporosis.  They can lead to acute and chronic pain as well as increased mortality.  Prolia is a fully human monoclonal antibody which has been approved for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone.  Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapy.  As this patient is at high risk for a fracture and has failed therapy with Fosamax, the Prolia injection performed on 8/27/15 was likely to have been more efficacious than other treatment options.  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 Overturned

Summary Reviewer 2


A 62-year-old female enrollee has requested reimbursement for Prolia injection performed on 8/27/15.  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 supports the services at issue in this patients case.  This patient has osteoporosis and has had multiple fractures.  She has been treated with Forteo and Prolia was subsequently prescribed.  Since she had fractures on Fosamax, there is sufficient support for the Prolia.  In sum, the Prolia injection provided on 8/27/15 was likely to have been of greater benefit than other treatment options.  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 Overturned

Summary Reviewer 3


A 62-year-old female enrollee has requested reimbursement for Prolia injection performed on 8/27/15.  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 patient has a history of osteoporosis and multiple non-traumatic fractures.  The patient is at a high risk for a major osteoporotic fracture, and pharmacological therapy is recommended.  The medical evidence supports Prolia in this clinical setting.  This patient has been treated with Fosamax, with no benefit on the patients bone mineral density.  The medical notes indicate that the patients markers of bone turnover were elevated, indicating poor absorption or increased bone turnover from rheumatoid arthritis while on Fosamax therapy.  Thus, the Prolia injection provided on 8/27/15 was likely to have been more effective than other treatment options.  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 Overturned

Summary Reviewer 1


A 42-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 10/7/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees breast cancer examination.  The physician reviewer found that the American College of Radiology urged tomosynthesis be removed from the investigational category in 2014 due to the advantage it brings radiologists interpreting mammograms especially in patients with dense breasts such as the patient under review. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural disorder resulting in a decrease in callbacks and increase in detection of small cancers compared to two-dimensional (2D) imaging alone. In this case, the use of tomosynthesis likely aided the radiologist to detect the area of interest in the left breast in this patient with dense breast tissue. Thus, the addition of tomosynthesis was likely of greater benefit to the patient than had her exam been done with 2D imaging alone. For this reason, the digital breast tomosynthesis performed on 10/7/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 42-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 10/7/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees breast cancer examination.  The physician reviewer found that the digital breast tomosynthesis performed on 10/7/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Skaane and colleagues performed a large prospective screening trial To assess cancer detection rates, false-positive rates before arbitration, positive predictive values for women recalled after arbitration, and the type of cancers detected with use of digital mammography alone and combined with tomosynthesis. The authors concluded that The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Given the support in the medical literature, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients breast exam than conventional mammogram.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 42-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 10/7/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees breast cancer examination.  The physician reviewer found that the Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In addition, there was identified a questionable mass, and tomosynthesis will often better localize, confirm, and characterize a mass. Accordingly, the digital breast tomosynthesis performed on 10/7/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

[INSERT FIRST TWO SENTENCES FROM SUMMARY REVIEW DETERMINATION] The physician reviewer found that as noted in the current medical literature, transanal hemorrhoidal dearterialization has been shown to have equivalent or superior outcomes when compared to standard available procedures. Ratto and colleagues concluded that transanal hemorrhoidal dearterialization appears to be a very effective minimally invasive option to treat hemorrhoids and can be performed in a day-surgery setting. Similar findings were reported by Sohn and colleagues. The records indicate this patients symptoms did not adequately respond to rubber band ligation or conservative measures. Given these findings, the Doppler guided transanal hemorrhoidal dearterialization provided on 11/20/17 was 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.