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

Summary Reviewer 2

A 48-year-old female enrollee has requested reimbursement for the lab testing provided on 11/28/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees migraines, mild memory impairment, and prior syncope. The physician reviewer found that this patient presented with a common problem that is migraine with aura. An extensive and expensive battery of testing for thrombophilia was ordered based on the providers concern about vascular risk factors. However, there is no mention of standard testing for vascular risk factors such as cholesterol levels, nor is there standard coagulation testing that might indicate an abnormal potential for thrombophilia. There is also no history of any coagulation issues in the past such as recurrent miscarriage, deep vein thrombosis, stroke, or myocardial infarction. As noted in the peer-reviewed medical literature, there is currently no role for the thrombophilia testing ordered by the provider in this clinical setting. Specifically, routine screening of homocysteine, Leiden V, and methylenetetrahydrofolate reductase (MTHFR) is not recommended due to positive testing in the asymptomatic general population. Many publications have guidelines for use of these tests, however this patient has none of the indications for thrombophilia testing. Thus, the lab testing provided on 11/28/16 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 testing 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 48-year-old female enrollee has requested reimbursement for the lab testing provided on 11/28/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees migraines, mild memory impairment, and prior syncope. The physician reviewer found that laboratory testing in patients with migraine headache, syncope, and cognitive impairment is not supported for hypercoagulable disorders in the absence of stroke or vascular disorder. The records do not reflect any vascular disorder or findings in support of stroke or ischemic brain event in this patient. Emmi and colleagues noted that laboratory evaluation is supported when there is vascular ischemic events. Antiphospholipid antibody syndrome should always be considered as a potential diagnosis especially for young patients presenting with a history of thrombotic events, in particular when they occur without any obvious external trigger or any inherited thrombophilic mutation, or for women with recurrent pregnancy losses or later fetal deaths. Migraine, syncope and cognitive disorders are not included as indications for this type of testing. Further, Reddy supports laboratory evaluation in setting of thrombotic events but not for diagnosis of migraine, syncope or cognitive disorder in absence of thrombotic event. Accordingly, the lab testing provided on 11/28/16 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 testing 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 Overturned

Summary Reviewer 


A 49-year-old female enrollee has requested reimbursement and prospective authorization coverage for transcranial magnetic stimulation (TMS) treatments provided from 9/20/16 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 major depressive disorder. The physician reviewer found that TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. TMS tends to be well tolerated with fewer barriers than electroconvulsive therapy. The American Psychiatric Association (APA) endorses TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. Although bipolar disorder is diagnosed in the medical record prior to the psychiatric assessment from 12/7/16, the records submitted for review fail to show evidence of mania or hypomania. Based on the records submitted, this patient has a unilateral mood disorder complicated by PTSD, marital discord, and a pathological personality organization which is steeped in psychodynamic theory. This would explain the refractoriness to bipolar treatments and the chronicity of symptoms with persistent negative schemas, impaired self-perception and recurrent patterns of maladaptive behavior. The medical record supports the presence of an acute-on-chronic depressive episode in context of major depressive disorder. Although TMS is not indicated for PTSD, its co-occurrence is not a contraindication to the therapy. Considering the clinical documentation, endorsement from the APA and the expanding peer-reviewed literature base, TMS represents a safe, appropriate treatment consistent with good medical practice.  Further, since this patient responded well to the therapy in the past, it is reasonably expected that another course of TMS will improve her condition and prevent a more serious episode of illness. In sum, the TMS provided from 9/20/16 forward was and is medically necessary for treatment of the patients behavioral health condition. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 62-year-old male has requested authorization and coverage for cervical total disc arthroplasty.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees neck pain and radiculopathy of arm. The physician reviewer found the current medical evidence has not demonstrated the superior efficacy of the requested services.  Per the medical records, the provider recommended cervical total disc arthroplasty due to concern regarding adjacent segment disease.  However, the literature regarding whether disc replacement prevents adjacent segment disease is equivocal.  There is no clear consensus that disc arthroplasty decreases the risk of developing adjacent segment disease.  In sum, the requested cervical total disc arthroplasty is not likely to be superior over other treatment options.  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 62-year-old male has requested authorization and coverage for cervical total disc arthroplasty.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees neck pain and radiculopathy of arm. The physician reviewer found the evidence-based medical guidelines and peer-reviewed literature do not support the use of an artificial disc replacement adjacent to a prior anterior cervical discectomy and fusion and in the setting of multilevel degenerative disc disease.  This patient presents with progressively worsening neck pain with right upper extremity radiculopathy in the C5 distribution.  Functional limitations were documented in activities of daily living and work activities.  Detailed evidence of a recent nonoperative treatment protocol trial and failure has been submitted.  Clinical examination findings were consistent with reported imaging evidence of nerve root compression at the C4-C5 level.  He was status post C5-C6 anterior cervical discectomy and fusion with adjacent segment disease at the C4-C5 and C6-C7 levels.  In sum, the requested cervical total disc arthroplasty is not likely to be of greater benefit than other treatment alternatives.  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 62-year-old male has requested authorization and coverage for cervical total disc arthroplasty.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees neck pain and radiculopathy of arm. The physician reviewer found this patient has a history of anterior cervical discectomy and fusion at C5-C6 and adjacent segment disease at C4-C5 with a large herniation.  There is evidence of a right C5 radiculopathy.  Conservative treatment has been tried and failed.  A review of the recent literature reveals that artificial disc replacement is superior to anterior cervical discectomy and fusion in that it will allow motion.  The requested procedure can maintain the range of motion of the replaced segment as well as the adjacent unfused segment. Based on this analysis, fusion plus disc replacement procedure has less severe biomechanical effects on adjacent levels when compared to bi-level fusion procedure.  Thus, the cervical total disc arthroplasty is likely to be of greater benefit than other treatment options.  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 Upheld

Summary Reviewer 

A 16-year-old male enrollee has requested reimbursement for psychiatric residential treatment provided from 11/07/17 through 10/26/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. In terms of risk of harm, the records support a score of 1. The patient was not actively suicidal and did not engage in self harm. With regards to functional status, the records support a score of 2. The patient had some issues with level of function due to mental illness and anxiety, but overall showed appropriate daily functioning while in treatment as evidenced by intact activities of daily living and cooperation in treatment. With regards to comorbidity, the records support a score of 2. The patient did not have a history of past medical issues but had past substance use. In terms of level of stress of the recovery environment, the records support a score of 2. The patient was noted to have a good relationship with family and denied stress at home have of a significant nature. With regards to level of support of the recovery environment, the records support a score of 2. The patients parent were involved in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient reported no past mental health treatment of a significant nature but had some response from attention deficit/hyperactivity disorder medication in the past. With regards to acceptance and engagement of the child, the records support a score of 2. The patient participated in therapy. In terms of acceptance and engagement of the parent, the records supported a score of 2. The patients parents worked actively and constructively with clinicians. Thus, the patient had a composite score of 16.  This score correlates with outpatient services. Therefore, psychiatric residential treatment provided from 11/07/17 through 10/26/18 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 56-year-old female enrollee has requested authorization and coverage for biliopancreatic bypass with duodenal switch (CPT code 43845). The Health Insurer has denied this request indicating that requested procedure is considered investigational for treatment of the enrollee, who has a history of morbid obesity and type 2 diabetes. The physician reviewer found that in this patients case, there is a lack of evidence that laparoscopic sleeve gastrectomy has failed or that duodenal switch will cure diabetes. She has been on Januvia and continues to lose weight. There is some evidence of noncompliance in diet and supplements. There is no direct intervention of stress eating and noncompliance with dietary and supplement restrictions. Moreover, there is a lack of documentation of whether her glycemic control has worsened in the last three years. The patients hemoglobin A1C is always documented as 7.2. This patient has not exhausted standard interventions for treatment of her diabetes. The patient would benefit from a full metabolic panel as well as dietary and psychiatric reevaluations. As such, the requested coverage for biliopancreatic bypass with duodenal switch (CPT code 43845) is not likely to be more effective than standard options available for treatment of this patient.
Based upon the information set forth above, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 56-year-old female enrollee has requested authorization and coverage for biliopancreatic bypass with duodenal switch (CPT code 43845). The Health Insurer has denied this request indicating that requested procedure is considered investigational for treatment of the enrollee, who has a history of morbid obesity and type 2 diabetes. The physician reviewer found that the documentation provided does not support the superior efficacy of the requested procedure in this clinical setting. It is not clear from the record whether this patient may benefit from conversion from sleeve gastrectomy to duodenal switch. The conversion cannot be determined without ensuring that this patient has been adequately evaluated and prepared for the different nutritional consequences ,including the need for fat soluble vitamins. The records provided do not document that this patient has been assessed behaviorally as to the increased potential risks related to re-operative surgery or that she has been deemed an appropriate candidate for the requested procedure. Both nutritional and psychological evaluations should be initiated. Therefore, biliopancreatic bypass with duodenal switch (CPT code 43845) is not likely to be superior to the available methods of treating this patients medical condition. Based upon the information set forth above, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 56-year-old female enrollee has requested authorization and coverage for biliopancreatic bypass with duodenal switch (CPT code 43845). The Health Insurer has denied this request indicating that requested procedure is considered investigational for treatment of the enrollee, who has a history of morbid obesity and type 2 diabetes. The physician reviewer found that there is support in the medical literature for the requested procedure in this clinical setting. Biliopancreatic bypass with duodenal switch is documented to be superior to medical management for treatment of weight loss. Duodenal switch is also associated with higher rates of diabetes remission, but there are some studies which link this procedure to higher rates of protein malnutrition. If the patient and her provider are prepared to deal with the potential outcomes that comes with this procedure, then biliopancreatic bypass with duodenal switch is an appropriate treatment option.   As such, biliopancreatic bypass with duodenal switch (CPT code 43845) is likely to be more effective than the medical management options for treatment of this patients medical condition. Based upon the information set forth above, the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The parent of a 12-year-old female enrollee has requested authorization and coverage for surgery (ApiFix procedure). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. At issue is whether the requested services are likely to be more beneficial for treatment of the enrollees condition than any available standard therapy. The physician reviewer found that the ApiFix procedure is a less invasive procedure compared to the standard rodding and fusion of idiopathic adolescent scoliosis. The procedure consists of pedicle screw based instrumentation inserted around the apex of the main scoliotic curve. There is a ratchet mechanism that elongates the device with postoperative exercises, resulting in a gradual curve correction. There is no need for a fusion. In the reference by Floman and colleagues, three adolescent females aged 13-16 years with curves between 43-53 and Risser sign of 1-4 underwent surgery with ApiFix. Two pedicle screws were inserted around the curve apex and the ratchet device was attached to the screws. No fusion was performed. Two weeks after surgery, the patients were instructed to perform exercises to correct the curve. Curves were reduced and maintained between 22- 33. Patients were pain-free and were able to perform their spinal exercises. Postoperatively, the expected gradual elongation of the device was observed. No curve progression was seen. The curves corrected with exercise and growth modulation. No complications were observed. There is sufficient support for the requested services in this setting. Therefore, the requested surgery (ApiFix procedure) is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


The parent of a 12-year-old female enrollee has requested authorization and coverage for surgery (ApiFix procedure). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. At issue is whether the requested services are likely to be more beneficial for treatment of the enrollees condition than any available standard therapy. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the requested services in this setting. Stadhouder and colleagues noted, The use of the unilateral peri-apical concave self-distracting ratchet rod initially was associated with promising clinical and radiographic results. However, no distraction was observed and the high rate of serious adverse events within 2 years was considered to be unacceptable for further clinical application of this device in our institution, despite recent FDA approval. Cheung and colleagues noted, Various emerging techniques in the surgical treatment of idiopathic scoliosis in children and adolescents have demonstrated promising results in the reported data thus far. However, longer term prospective studies with larger cohorts are necessary to better evaluate their safety and efficacy. This patient has been diagnosed with adolescent idiopathic scoliosis. She had presented in consultation for scoliosis. She had not had any scoliosis intervention. She has been wearing her brace. Clinical and radiographic findings evidence a significant probability of ongoing major spinal curve progression. However, overall published quality, peer-reviewed literature does not support or evidence the request to be an effective and/or safe treatment for adolescent idiopathic scoliosis. Further studies are needed to adequately demonstrate the overall safety and/or efficacy of the requested ApiFix. Therefore, the requested surgery (ApiFix procedure) is not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

The parent of a 12-year-old female enrollee has requested authorization and coverage for surgery (ApiFix procedure). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. At issue is whether the requested services are likely to be more beneficial for treatment of the enrollees condition than any available standard therapy. The physician reviewer found that this patient was diagnosed with scoliosis when she was nine years old. At the time, her curve was only 10 degrees. Recently, the patient has had a growth spurt. Despite bracing, the curve has grown. The patient and her family are requesting a growth friendly modulation surgical approach and would like to avoid permanent fusion. The current medical evidence supports the requested services in this clinical setting. The ApiFix procedure is backed by nine years of clinical experience. There is substantial clinical experience and evidence now showing the validity and its efficacy in adolescent idiopathic scoliosis. Therefore, the requested surgery (ApiFix procedure) is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


The parent of a six-year-old male enrollee has requested authorization and coverage for Saizen 8.8 mg click easy cartridge.  The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition The physician reviewer found there is sufficient support for the requested medication in this clinical setting.  This patient was born small for gestational age with lack of catch-up growth, growth hormone abnormalities (indicative of deficiency without stimulation testing), and small pituitary gland on MRI.  He was treated successfully in the past, with significant improvement in growth velocity, but the medication was discontinued prematurely and his height is now more than two standard deviations below the mean.  There are two ways to determine duration of therapy: administration of growth hormone when near adult height is achieved, or discontinuation of therapy when the height is in the normal adult range, less than two standard deviations from the mean. Either course of action is appropriate.  All told, Saizen 8.8 mg click easy cartridge is likely to be of greater benefit than other treatment options.  Based upon the information set forth above, the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.