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

Summary Reviewer 




The parent of a 14-year-old male enrollee has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment center (RTC) services provided from 11/7/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees attention deficit hyperactivity disorder (ADHD) and anxiety. The physician reviewer found that based on current guidelines including the Child and Adolescent Level of Care Utilization System (CALOCUS), the RTC services provided from 11/7/16 forward were not and are not medically necessary for treatment of this patients medical condition. As noted by the CALOCUS, the patient was at some risk of harm due to episodic outbursts but is not having active suicidal ideation or other behaviors or thoughts. In addition, the patients functional status is moderate, the patient has had minimal school disruption and is able to complete activities of daily living in an age appropriate manner. Further, the patient does not have active serious medical problems and although he has issues with family relationships, he has a stable housing situation if accepted home. The patients resiliency and treatment history is moderate due to minimal positive treatment response in the past and the patient participates actively in therapy but has poor insight and is obstructive at times. Overall, this patients presentation supports treatment in a less restrictive setting such as intensive outpatient program (IOP). It appears that the patient has sufficiently stabilized to allow transition to a less restrictive setting. The majority of the patients current issues are due to continued oppositional behaviors and the patient has made progress related to his treatment goals. The patients goals are similar to those that would occur on an outpatient basis. Accordingly, the medical records do not support the medical necessity of the RTC services provided from 11/7/16 forward for treatment of this patients behavioral issues. Based on the available documentation, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 38-year-old male enrollee has requested reimbursement for genetic testing performed on 5/31/18. 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 while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign. The relatively new development of molecular techniques and the identification of genetic alterations associated with different follicular cell-derived cancers in the thyroid have led to the introduction of several commercially available tests. Among these tests is ThyGenX, which analyzes a panel of DNA mutations and RNA translocation fusion markers to assess the risk of malignancy with good negative and positive predictive value, thereby obviating the need for unnecessary surgeries. Therefore, genetic testing performed on 5/31/18 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 38-year-old male enrollee has requested reimbursement for genetic testing performed on 5/31/18. 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 molecular testing has emerged as a promising method for clarifying the gray area of indeterminate thyroid fine needle aspirations, with the aim of reducing the overtreatment of benign nodules and increasing the preoperative detection of malignant nodules that should be treated by a single surgery (total thyroidectomy) rather than a two-step procedure. When molecular testing informs patient management, it should be further integrated with clinical findings and ultrasonographic results. As additional information accumulates to further refine these integrated approaches to patient management, the genetic information provided by molecular tests is expected to increasingly individualize the management of patients with thyroid nodules and cancer. In this patients case, a second thyroid biopsy was not necessary because this test was done as a follow-up of an indeterminate result. A benign result by the ThyGenX/ThyraMIR test has a significant negative predictive value. The medical evidence supports the services at issue in this clinical setting. All told, genetic testing performed on 5/31/18 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 38-year-old male enrollee has requested reimbursement for genetic testing performed on 5/31/18. 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 sufficient support for the services at issue in this clinical setting. This patients initial biopsy was suspicious for follicular neoplasm. Genetic testing could obviate the need for a surgical procedure. Genetic testing on thyroid nodules is generally considered standard protocol on all fine needle aspirations done on thyroid nodules. The literature indicates that this testing can be performed to avoid unnecessary surgeries. The results from this testing may influence patient management. Thus, genetic testing performed on 5/31/18 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 64-year-old female has requested reimbursement for vedolizumab infusions provided on 5/03/19 and 6/28/19. The Health Insurer has denied this request and reported that the medication at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medication at issue in this clinical setting. The patient has been diagnosed with ulcerative colitis. She has failed to respond to Humira, and is intolerant to prednisone due to its hyperglycemic effect on her diabetes. She previously was maintained on vedolizumab infusions every eight weeks. Colonoscopy showed active ulceration, prompting dose optimization to infusions every six weeks. In this patients case, colonoscopy demonstrated mucosal disease on every eight-week Entyvio infusions. As such, the records demonstrate loss of Entyvio response to warrant the dose escalation. Therefore, vedolizumab infusions provided on 5/03/19 and 6/28/19 were likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 64-year-old female has requested reimbursement for vedolizumab infusions provided on 5/03/19 and 6/28/19. The Health Insurer has denied this request and reported that the medication at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient has been diagnosed with ulcerative colitis. The U.S. Food and Drug Administration has approved vedolizumab for induction of remission and maintenance of remission in moderate to severe ulcerative colitis. The patient was previously treated with Humira, but had side effects, including hair loss. The patient was started on vedolizumab and received infusions on 5/03/19 and 6/28/19. In this patients case, there are no progress notes or other information from the provider documenting that vedolizumab was working. There is insufficient documentation of benefit for the continued use of this medication. All told, vedolizumab infusions provided on 5/03/19 and 6/28/19 were not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 64-year-old female has requested reimbursement for vedolizumab infusions provided on 5/03/19 and 6/28/19. The Health Insurer has denied this request and reported that the medication at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer that the found Entyvio (vedolizumab) is an integrin antagonist specific to the gastrointestinal tract. It has a different mechanism of action than immunosuppressants and anti-tumor necrosis factor (TNF) agents, such as Remicade and Humira for ulcerative colitis. Entyvio is recommended as a first-line therapy for ulcerative colitis. Entyvio is effective for ulcerative colitis, with minimal side effects.
In this case, Entyvio is more appropriate than any alternatives. A change to an alternative could result in lack of response or complications of uncontrolled ulcerative colitis. Thus, vedolizumab infusions provided on 5/03/19 and 6/28/19 were likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 23-year-old male enrollee has requested reimbursement for mental health residential treatment provided from 5/10/15 through 8/05/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions.  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was not a danger to himself or others.  The records do not document that he was aggressive, agitated, hostile, manic, or psychotic.  There was no physician evaluation on admission, psychiatric or otherwise.  There were no skilled nursing services provided.  Groups were on a weekly, not daily, basis, and records do not show that therapeutic services were provided on a multiple-hours per day basis.  The current medical evidence does not support the services at issue in this patients case, as there is no record of his behavior being hostile, aggressive, risky, dangerous to himself or others, or out of control prior to admission.  The patient could have been treated on an outpatient basis, which would have been seen as the standard of practice in the community.  All told, mental health residential treatment provided from 5/10/15 through 8/05/15 were 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 51-year-old female enrollee has requested reimbursement for air ambulance services provided on 11/29/16. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition status post subarachnoid hemorrhage. The physician reviewer found the air ambulance services provided on 11/29/16 were medically necessary for treatment of the patients medical condition. There is sufficient support in the peer-reviewed literature to support the services at issue in this clinical setting. Pollock and colleagues reviewed whether physical rehabilitation approaches are effective in recovery of function and mobility in patients with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach. The authors found that physical therapy improved recovery from stroke. In this case, the patient sustained a stroke and a facility in Washington did not accept her. She was transferred by air ambulance to Colorado for acute rehabilitation. The medical literature supports the therapies delivered at the Craig Hospital in Colorado which is the standard treatment approach for patients status post stroke. Given the patients medical condition, the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 52-year-old male enrollee has requested reimbursement and prospective authorization and coverage for physical therapy from 5/02/16 forward.  The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the literature related to rehabilitation after anterior cruciate ligament reconstruction supports early weight-bearing, early range of motion exercise, and closed kinetic chain activities.  The early rehabilitation process should be monitored closely to protect against graft failure and other complications.  As strength improves, open kinetic chain activities and more functionally advanced work can be introduced, although demanding physical activity is generally avoided during the first three postoperative months.  Overall, rehabilitation following anterior cruciate ligament reconstruction can require a prolonged period of time.  However, the entire rehabilitation process following anterior cruciate ligament reconstruction does not require a formal therapy setting.  In this patients case, the therapy interventions and modalities which have been provided have included manual therapy, supervised exercise, home exercise instruction, and palliative modalities. In the physical therapy notes available for review, the chief complaint and daily comments sections appeared only intermittently updated.  There is only limited indication of therapeutic exercises or interventions that need formal physical therapy supervision or provision.  This patient has undergone extensive formal training and does not have cognitive or other impairments that would preclude a predominantly (but not fully) independent program.  His predominantly independent program does need periodic review, adjustment and reinforcement, particularly as new activities are introduced.  Based on the available clinical records, one visit per month for supervised therapy was and is medically indicated for these purposes.  He remains at substantial risk for suboptimal outcomes due to the chronicity, severity and nature of his underlying conditions, with or without prolonged and intensive ongoing formal physical therapy.  Notably, the enrollee has made very slow and limited progress to date despite his ongoing intensive formal therapy.  All told, one physical therapy visit per month from 5/02/16 forward was and is medically indicated for the treatment of this patient.  Therefore, a portion of the services at issue was and is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 53-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/25/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination.  The physician reviewer found that there is evidence based support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely to be more effective than had her examination been performed using two dimensional imaging alone. Based upon the information set forth above, the service at issue was likely to have been 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 53-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/25/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination.  The physician reviewer found that according to Skaane and colleagues, 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.  Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, breast tomosynthesis performed on 7/25/16 was likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the service at issue was likely to have been 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 53-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/25/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination.  The physician reviewer found that Breast 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 scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  However, in this patients case, there were no problems to be resolved.  The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications.  In this clinical setting, a routine mammogram would have been sufficient.  Digital breast tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality. Therefore, breast tomosynthesis performed on 7/25/16 was not likely to have been of greater benefit than other modalities for evaluating this patient. Based upon the information set forth above, the services at issue were not likely to have been 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 Overturned

Summary Reviewer 


A 53-year-old male enrollee has requested reimbursement for the wearable cardioverter defibrillator provided from 8/27/14 through 10/15/14. 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 review of the submitted documentation and relevant literature demonstrates the medical necessity for the services at issue. Based on the documentation provided for review, the patient is a 53-year-old male with a newly recognized cardiomyopathy in the setting of rapid atrial fibrillation and syncope on 8/19/14. The cause of the syncope is not certain and may have been due to a sustained ventricular dysrhythmia in this setting. Therefore, protection against the possibility of recurrent syncope from ventricular tachycardia by placement of a defibrillator is indicated and considered standard accepted practice in the medical community (Russo, et al). Defibrillator placement was also recommended by the provider treating the patient at the time. However, defibrillator placement needed to be delayed both to see if the patients cardiomyopathy was reversible after cardioversion out of atrial flutter and because his INR was too high. During this period of delay it was reasonable and appropriate, to prescribe an external wearable defibrillator to help protect against recurrent syncope. A prophylactic wearable external defibrillator is indicated since accepted criteria for an implantable defibrillator were met (unexplained syncope in setting of severe cardiomyopathy) and placement of an implantable defibrillator needed to be significantly delayed. Therefore, the wearable cardioverter defibrillator provided from 8/27/14 through 10/15/14 was medically necessary for the treatment of the patients medical condition. For the reasons provided, 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 20-year-old female enrollee has requested authorization and coverage for arthroscopy of the knee. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee, who has a history of knee pain. The physician reviewer found that the peer reviewed literature supports arthroscopy debridement of cyclops lesions, lysis of adhesions and manipulation under anesthesia of the knee to restore full knee extension when loss of full extension and painful stiffness persist, despite aggressive rehabilitation following anterior cruciate ligament reconstruction. This patient presents with persistent right knee pain and stiffness nearly three years status post anterior cruciate ligament reconstruction for complete rupture. The submitted documentation supports the patients loss of full extension. There is documented pain consistent with imaging evidence of synovitis, intercondylar notch scar tissue, and possible cyclops lesion. Evidence of long-term reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted. As such, the requested services are medically necessary for treatment of this patients medical condition.  Therefore, based on the reasons stated above, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.