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

Summary Reviewer 3


A 48-year-old female enrollee has requested reimbursement for lab testing (Factor V Leiden genetic testing) provided on 12/16/14. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that there is a lack of support in the peer-reviewed literature for the Factor V Leiden genetic testing performed in this clinical setting. In this case, the patient does not have a personal history of venous thromboembolism (VTE). Moreover, the testing at issue is not the standard of care as it is not supported for population testing. The position statement by the North American Menopause Society (NAMS) states Women with a previous history of VTE, obese women, or women who possess a Factor V Leiden mutation are at increased risk of VTE with HT use. However NAMS does not recommend Factor V Leiden population testing such as in this case, with no indication for testing by medical or family history. 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 Upheld

Summary Reviewer 

The patient is a 62-year-old male with irritant dermatitis. Per the provider, the patient is a candidate for treatment with Urea 40% cream. The patient has requested authorization and coverage for Urea cream. The Health Insurer has denied this request indicating that the requested medication is not medically necessary.The records indicate that this patient has tried and failed therapy with topical steroids and long-term usage of such is contraindicated due to risks of skin atrophy. Urea 40% cream is a keratolytic agent that helps to reduce a build-up of scale and adherent skin, and is not considered a typical agent for the treatment of irritant dermatitis. Moreover, a prescription is not needed for this medication as Urea 40% cream can be obtained over the counter. All told, the requested Urea cream is not supported as medically necessary for treatment of this patients medical condition. 

Based on the foregoing discussion, the requested medication is 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 

The patient is a 49-year-old female with a history of ex pleomorphic adenoma of her right lacrimal gland. The patient has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that this case was previously reviewed, and additional documentation was submitted for reconsideration. The additional documentation includes a letter from the provider and a photon/proton plan comparison. Based on the provided photon/proton plan comparison, the requested proton beam therapy is medically indicated. The photon-based plan results in excessive and potentially dangerous radiation exposure to the patientas right optic nerve and cornea, which will place the patient at an unnecessarily high risk for right eye pain and blindness.  The proton radiation therapy plan is able to significantly reduce the exposure to these right eye structures, and accomplish known treatment planning objectives. The additional records demonstrate that the patient cannot be treated safely and effectively with photon-based radiation therapy. Therefore, proton beam therapy is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 30-year-old female enrollee has requested reimbursement for knee orthosis provided on 1/04/19. The Health Insurer has denied this request and reported that the device at issue was not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the device at issue in this patients case. The current evidence-based literature supports the use of unloader braces for patients with osteoarthritis of the knee to improve pain and physical function. This patient was diagnosed with right knee osteochondral dissecans defect of the medial femoral condyle and underwent cartilage repair surgery on 11/08/18. A postoperative prefabricated medial unloader brace was prescribed to unload the repaired cartilage defect as she resumed maximal functional activity. Evidence-based guidelines support knee bracing in this clinical setting, and the literature supports use for improved pain and physical function generally. Therefore, the knee orthosis provided on 1/04/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

The patient is a 54-year-old male with a history of left hip pain of two years duration. The pain limits his physical activities including jogging and walking. The pain is anterolateral. There is some intermittent catching. He has tried and failed conservative treatment including physical therapy. On examination, there is a slight antalgic limp. The record notes that his hip range of motion is slightly limited. There is a positive McCarthys sign. FADIR impingement sign is also positive. X-rays show CAM type femoroacetabular impingement. The magnetic resonance (MR) arthrogram dated 9/7/17 showed long standing CAM type femoroacetabular impingement with labral damage. The osteoarthrosis is associated with a subchondral cyst in the acetabulum. The alpha angle is 73 degrees. There is a labral tear as well. The patient reports that he does not want a hip replacement. The provider indicates that the patient meets criteria for arthroscopy of the left hip, labral repair versus debridement and femoroplasty. The Health Insurer has denied the requested services as not medically necessary for the treatment of the patient. This denial is the subject of this appeal and determination. There is support in the medical literature for the requested services in this clinical setting. Femoroacetabular impingement is an important cause of labral tears, chondral lesions, hip pain and a leading cause of early osteoarthritis.  Different surgical techniques for the management of femoroacetabular impingement have evolved rapidly over the last decade. The aim of surgery is to correct symptomatic CAM and Pincer abnormalities and reduce secondary osteoarthritis early on; thereby preventing progressive osteoarthritis, while minimizing complications associated with surgery. The medical data indicates that arthroscopic technique has a low complication rate. In this case, the patient has labral tears, CAM type femoroacetabular impingement and early to moderate degenerative changes. The physical findings and MR arthrogram confirm the femoroacetabular impingement and associated damage. The patient has reported gradual worsening of his symptoms. The provider believes that correcting the femoroacetabular impingement with femoroplasty and possibly repairing the torn labrum will likely help the symptoms and slow down the progression of osteoarthritis. A review of the recent medical literature supports the requested services in this patients case. As such, arthroscopy of the left hip, labral repair versus debridement and femoroplasty have been demonstrated as medically necessary for the treatment of this patients medical condition. Therefore, based on the reasons stated above, the requested services are medically necessary for the treatment of this patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


The parent of a 14-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 2/24/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Providers utilize the testing at issue as a standard therapy after starting infliximab to judge whether someone will benefit from the drug. It lets the provider know if the serum levels of drug are in the range to be beneficial and effective or if they have antibodies that could potentially lead to a reaction or failure to respond. This can help guide the provider in dosing or may lead to discontinue the drug if the patient is not likely to benefit from the medication. This can not only prevent the patient from having a flare, but save them from potential side effects of a drug they may not benefit from. The patient may be exposed to the drug unnecessarily without using this testing. Knowing this before a flare-up occurs can save the patient from a potential inpatient hospitalization as well. All told, the testing at issue 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 testing 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 Upheld

Summary Reviewer 2

The parent of a 14-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 2/24/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the Anser IFX testing performed on 2/24/15 was not likely to be more effective for this patient than other available options. The Prometheus Anser IFX test is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies, and the Anser ADA test assesses serum adalimumab (ADA) and anti-ADA antibodies. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or adalimumab or the presence of IFX or ADA antibodies have an adverse effect on the clinical outcome of a patients response to treatment. While however there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al). In sum, it has not yet been established in the peer-reviewed literature whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Given the above, the testing at issue 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


The parent of a 14-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 2/24/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees medical condition.The physician reviewer found checking infliximab levels and antibodies has been demonstrated to be helpful in guiding clinical decision making when there is concern for a loss of response to infliximab. However, in this case, the patient was apparently in remission at the time of testing, with labs drawn to proactively monitor infliximab levels and antibodies. While this approach is being studied, there is not yet robust evidence that it will improve clinical outcomes. Vaughn and colleagues performed a retrospective observational study of proactive monitoring of infliximab troughs and antibodies. The authors found that among the 48 patients with proactive monitoring, the likelihood of remaining on infliximab (presumably due to sustained response) was higher than for controls. While this approach is certainly promising, and may well become standard of care in future, at this point it is not the standard of care. Therefore, the Anser IFX diagnostic testing performed on 2/24/15 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 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 Upheld

Summary Reviewer 

The patient is a 53-year-old male with history of diabetes, hypertension and hyperlipidemia. The patient has requested reimbursement for inpatient stay provided from 7/26/19 through 7/29/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that the patient had progressive chest discomfort and an equivocal outpatient stress test. The plan for coronary angiography had already been determined. However, his symptoms progressed so he came to the emergency department and he was ruled out for myocardial infarction. The angiography plans were moved up, and he was admitted. Coronary angiography was indicated in this patient and doing it sooner than originally scheduled was medically appropriate. Although he did not have indicators for emergent angiography on the night of admission as his electrocardiogram was normal, his symptoms resolved and his troponins negative, he still required angiography and that was the medical plan. However, this did not occur until three days later on 7/29/19. There was no clinical reason stated for this relatively long delay of the planned diagnostic procedure, other than he presented on Friday evening and the catheterization was scheduled for Monday morning. If it was felt the patient was too high risk and could not go home to return Monday for the catheterization, then it could have been carried out the next day and the patient discharged thereafter as no obstructive disease was found. He did not rule in for myocardial infarction, his electrocardiogram was normal, he had no congestive heart failure or arrhythmia, his chest discomfort had resolved and the stress test was already completed, so he did not meet criteria for inpatient care. He met criteria for observation level of care with short stay based on both the initial clinical presentation and his clinical course. The inpatient stay was not medically necessary and observation level of care was appropriate. Therefore, inpatient stay provided from 7/26/19 through 7/29/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 63-year-old male enrollee has requested authorization and coverage for Repatha. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees hyperlipidemia. The physician reviewer found that this patient has been diagnosed with hyperlipidemia, documented obstructive coronary disease and documented inability to tolerate statin therapy. However, there is no reported trial or intolerance to ezetimibe. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. Since ezetimibe has been demonstrated to be safe, well-tolerated, effective at lowering LDL cholesterol, and associated with improved outcomes, it is medically appropriate to trial this medication prior to determining the need for a PCSK9 inhibitor such as Repatha.  Repatha is not medically indicated at this time since the need for additional LDL lowering has not been documented while on ezetimibe. All told, Repatha is not medically necessary for the treatment of this patient. Therefore, the requested medication is 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 33-year-old male enrollee has requested authorization and coverage for Epidiolex 100 mg/mL solution. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The patient has been on multiple anti-epileptic medications, including Keppra, gabapentin and Lamictal. He continues to demonstrate seizure activity. In cases where patients are refractory to traditional therapies, the use of cannabidiol has demonstrated significant benefit in controlling seizure activity. As this patient has not responded to traditional therapies, the use of Epidiolex is medically appropriate. Therefore, Epidiolex 100 mg/mL solution is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 55-year-old male who was hospitalized from 6/08/20 through 6/11/20. The patient has requested reimbursement for air ambulance services provided on 6/11/20. The physician reviewer found that in order for air medical transport to be medically necessary, all medical necessity criteria must be met. These criteria include: the individualas condition must be such that any form of transportation other than ambulance would be medically contraindicated; the individualas condition is such that time needed to transport by ground poses a threat to the patientas survival; the individual is transported to the nearest hospital with appropriate facilities for treatment; and there is a medical condition that is life-threatening. When transporting from one facility to another, the above criteria must be met, and the first hospital does not have the required services and facilities to treat the patient. The patientas provider noted that El Centro Regional Medical Center does not have an intensivist available to help manage an intubated patient and that was the reason for transfer to Cedar Sinai. It appears from this provideras note that Cedar Sinai was the closest available facility with an intensive care unit (ICU) available capable of accepting the patient. Therefore, air ambulance services provided on 6/11/20 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 40-year-old female enrollee has requested authorization and coverage for Aimovig. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who has been diagnosed with chronic daily migraine. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has taken several migraine prophylactic medications without success.  However, the Health Insurer has requested that the patient fail two medications (for at least two months each) amongst a list of several options.  With regards to these alternatives, the documentation provided shows the patient has failed onabotulinumtoxinA. While there is mention of topiramate in the submitted documentation, there is insufficient information regarding the parameters of this failure, including, but not limited to, length of therapy prior to failure. There is a lack of evidence indicating superiority of Aimovig compared to the alternatives offered by the Health Insurer. All told, Aimovig is not medically necessary for the treatment of this patient. Therefore, the requested medication is 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 


The parent of a three-year-old male enrollee has requested reimbursement and prospective authorization and coverage for nine additional weekly hours of applied behavioral analysis (ABA) therapy provided from 10/31/16 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 autism spectrum disorder. The physician reviewer found in this clinical setting, nine additional weekly hours of ABA therapy provided from 10/31/16 forward were and are medically necessary for treatment of the patients medical condition. The study by Linstead and colleagues evaluated the relationship between ABA treatment intensity and treatment outcomes for individuals with autism spectrum disorder. The authors reported a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress was demonstrated. In this case, the patient is making slow, steady progress, but continues to have significantly problematic behaviors in the areas of social skills, social-emotional awareness and safety. He is a significant flight risk with several episodes of elopement. He continues to demonstrate impairment in several areas making it increasingly difficult for him to be successful in more generalized environments. The Health Plan has 22 hours of direct ABA therapy and along with one hour per week of individual parent training and two hours of supervision per week, which is less than what is recommended for optimal response. Several studies have recommended 25 or more hours of direct weekly ABA to ensure optimal outcomes (Roane et al; Myers et al). The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30-40 hours of treatment per week. Given the support cited above, nine additional weekly hours of ABA therapy provided from 10/31/16 forward has been established as medically necessary for treatment of the patients medical 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.