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

Summary Reviewer 

A 20 year-old male enrollee has requested reimbursement for psychiatric acute inpatient treatment from 11/17/18 through 11/29/18. 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, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 3 due to a lack of current suicidal ideation but a history of this as his presenting issue. With regards to functional status, the records support a score of 2 due to overall good daily function while on the inpatient unit. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to a history of substance use and commitment to sobriety as well as no active significant medical issues. With regards to level of stress of the recovery environment, the records support a score of 2 due to some apparent peer relationship issues. In terms of level of support of the recovery environment, the records support a score of 2 due to a sober living environment and support of parents. With regards to treatment and recovery history, the records support a score of 2 due to positive response to inpatient treatment. In terms of engagement and recovery status, the records support a score of 2 due to good cooperation in treatment and noted current insight into the need for treatment. Thus, the patient has a composite score of 15. This score correlates with community-based services. Therefore, psychiatric acute inpatient treatment from 11/17/18 through 11/29/18 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer

The patient is a 29-year-old female who presented to her provider for prenatal care at a gestational age of 22 weeks. At 18 to 20 weeks gestation, a screening anatomy scan was performed and a thickened nuchal fold was noted. This was again confirmed on a follow up ultrasound and a subsequent recommendation for chromosomal testing was offered. The provider discussed the option of amniocentesis or cell free DNA screening. The patient had opted for cell free DNA screening. The patient has requested reimbursement for fetal chromosomal aneuploidy genomic sequence performed on 9/18/17. The Health Insurer denied reimbursement and reported that the services at issue were not medically necessary for the evaluation of this patients medical condition. There is support for the medical necessity of the services at issue in this clinical setting. The American College of Obstetrics and Gynecology (ACOG) in conjunction with the Society for Maternal Fetal Medicine addressed the issue of the use of cell free DNA testing. The Committee Opinion recognized patient option to choose noninvasive prenatal testing as a strategy to screen for aneuploidy regardless of the patients risk status but does so with the caveat that she understands the limitations and benefits of this screening paradigm in the context of alternate screening and diagnostic options. Essentially, ACOG Committee has defined testing as it relates to low risk and high risk patients. In this case, the patient met the criteria for high risk setting due to a thickened nuchal fold that was noted by a screening anatomy scan at 18 to 20 weeks gestation and again confirmed on a follow up ultrasound. This finding, although isolated, is associated with an increased risk of aneuploidy specifically Trisomy 21. Nuchal edema or fold which is measured at more than 6 mm is found in about 0.1 to 0.5% of fetuses. It may be of no pathological significance; however, these findings may be associated with chromosomal defects, cardiac anomalies, infection or genetic syndromes. The measurement is considered abnormal if it is 6 mm or greater.  In this case, the patients nuchal edema or fold was 6.4 and was elevated for all gestational ages between 15 to 24 weeks. Using a threshold of 6 mm, or greater, as an abnormal measurement, 40% of the fetuses with trisomy 21 were identified with a thickened nuchal fold. A thickened nuchal fold is also associated with euploid syndromes, such as the Noonan syndrome, as well as with heart defects. In sum, the fetal chromosomal aneuploidy genomic sequence performed on 9/18/17 was medically necessary for the evaluation of this patient.Therefore, for the reasons stated above, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 56-year-old female enrollee has requested reimbursement for the Foundation One genetic testing provided on 1/12/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees recurrent ovarian cancer.  The physician reviewer found  that the Foundation One assay tests for the presence of a wide array of molecular markers that have been demonstrated to be of relevance in the pathogenesis of various cancers. Screening for the presence of these markers in a tumor may provide information relevant to the selection of potentially active therapeutic agents. Several commercially available assays are currently available which provide similar information. This methodology is promising, but with few exceptions, the level of evidence supporting clinical decision-making using genomic profiling is at present not of sufficient quality and maturity to inform current standards of care (Doroshow). According to the National Comprehensive Cancer Network (NCCN) guidelines, genomic profiling is not mentioned, and is not considered a standard of care. A recent review from Kohn similarly asserted that, tumor profiling done for therapeutic guidance is currently premature, save BRCA1 and BRCA2 mutation testing, and when done, should rely on validated ovarian cancer-specific treatment data. All told, the Foundation One genetic testing performed on 1/12/15 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, I have determined the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2
A 56-year-old female enrollee has requested reimbursement for the Foundation One genetic testing provided on 1/12/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees recurrent ovarian cancer.  The physician reviewer found that per National Comprehensive Cancer Network (NCCN) compendia and American Society of Clinical Oncology (ASCO), chemotherapy sensitivity assays have a category 3 recommendation as there is a lack of robust evidence that their use translates into a benefit for the patient. Moreover, these chemotherapy sensitivity assays are not considered the standard of care. There are numerous regimens to choose from in this clinical setting without the use of a chemotherapy sensitivity assay, based upon well controlled peer-reviewed literature. Thus, the Foundation One genetic testing performed on 1/12/15 was not likely to have provided this patient with an improved health outcome when compared to standard available therapies. Based upon the information set forth above, I have determined the services at issue were 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 56-year-old female enrollee has requested reimbursement for the Foundation One genetic testing provided on 1/12/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees recurrent ovarian cancer.  The physician reviewer found that molecular profiling is an assay of an individual patients cancer cells to detect specific genomic or molecular abnormalities that might serve as a target for a potential treatment. There are multiple non-randomized clinical trials exploring the value of molecular profiling. However, there is a lack of data from these trials demonstrating improved health outcomes based on the findings in these assays (Von Hoff, et al). Currently, there is a paucity of scientific data suggesting that the Foundation One genetic testing performed on 1/12/15 was likely to have been more beneficial for evaluation of this patients medical condition than standard available testing. Based upon the information set forth above, I have determined the services at issue were 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 44-year-old male with a history of morbid obesity and hypercholesterolemia. The patient has requested authorization and coverage for Saxenda. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that according to the U.S. Food and Drug Administration (FDA), Saxenda is approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index of 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (eg, hypertension, type 2 diabetes mellitus, dyslipidemia).  The initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention: a combination of diet, exercise, and behavioral modification. All patients who would benefit from weight loss should receive counseling on diet, exercise, and goals for weight loss.  When a patient with a body mass index greater than 30 kg/m2 or a BMI of 27 through 29.9 kg/m2 with comorbidities, such as hypertension or diabetes mellitus, has failed to achieve weight loss goals through diet and exercise alone, pharmacologic therapy is suggested. In this case, limited documentation was provided despite requests. The submitted records do not document that the patient has failed treatment with counseling, calorie restriction and increased physical activity to achieve weight loss goals. Therefore, Saxenda is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 30-year-old male enrollee has requested reimbursement for chemical dependency intensive outpatient treatment provided from 5/22/18 through 5/29/18. 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 that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient did not demonstrate or complain of post-acute withdrawal symptoms.  He was not a danger to himself or others. There were no emotional, behavioral, cognitive, or impulsive symptoms which would have prevented step down to outpatient level of care. He was medically and psychiatrically stable, and his Wellbutrin could have been managed in an outpatient setting. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He was cooperative, motivated, and participating in his treatment plan. No new problems had arisen. The patient demonstrated good insight and motivation, and there was no evidence to suggest that he would not successfully continue his recovery in the outpatient setting, in conjunction with community support, such as 12-step program with counseling. All told, chemical dependency intensive outpatient treatment provided from 5/22/18 through 5/29/18 was not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 58-year-old female enrollee has requested authorization and coverage for the LINX device.  The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD) and esophagitis. The physician reviewer found that overall, there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The currently available peer-reviewed literature does not support the conclusion that LINX is more likely to be beneficial in this case than standard treatment including surgical fundoplication (Sheu, et al; Ganz). Further, the American College of Gastroenterology (ACG) guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). For these reasons, the requested LINX device 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 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 58-year-old female enrollee has requested authorization and coverage for the LINX device.  The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD) and esophagitis. The physician reviewer found that the LINX device received U.S. Food and Drug Administration (FDA) premarketing approval in March 2012. The approved indication was for patients with diagnosed GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. Currently, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative work-up for antireflux surgery (Jobe, et al). This patient has undergone much of this pre-operative assessment. Although this patient has GERD as based on pH recording and Barretts histology, the available records do not demonstrate that she is medically refractory to acid blocker drugs. Also, implantation of LINX in this patients setting must be approached with caution given her documented esophageal dysmotility and functional outlet obstruction and because LINX has not been adequately evaluated in patients with Barretts esophagus. As such, the requested LINX device is not likely to be more beneficial than available standard therapy for treatment of 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 58-year-old female enrollee has requested authorization and coverage for the LINX device.  The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD) and esophagitis. The physician reviewer found that one of the main adverse events related to the placement of a LINX device is dysphagia. When severe, these symptoms could lead to the need to remove the device. This patient has a hypertensive LES and EGJ outflow obstruction along with a history of a food impaction. Therefore, this patient is at markedly increased risk for having dysphagia or future events of food bolus obstruction if the LINX is placed. Additionally, the patients underlying motility disorder is likely contributing to her symptoms as she experiences frequent symptoms 24-hours per day, but only has a borderline positive study for acid reflux. All told, the requested LINX device 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 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 Overturned

Summary Reviewer 1


A 56-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/21/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  Breast tomosynthesis allows radiologists to separate dense glandular elements from underlying mass/architectural distortion.  This has resulted in a decrease in callbacks and increase in detection of small cancers.  In this patients case, the detection of the abnormality in the right breast resulted in an ultimate diagnosis of breast cancer.  Therefore, the addition of breast tomosynthesis to two-dimensional imaging likely was of more benefit to the patient than had she undergone two-dimensional digital mammogram alone.  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 56-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/21/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the medical literature supports the services at issue in this patients case.  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.  All told, breast tomosynthesis performed on 7/21/15 was likely to have been of greater benefit than other methods of evaluating this patient.  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 56-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/21/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found breastmedical literature supports the services at issue in this patients case.  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.  All told, breast tomosynthesis performed on 7/21/15 was likely to have been of greater benefit than other methods of evaluating this patient.  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

A 54-year-old male enrollee has requested authorization and coverage for neurostimulator electrode array and pulse generator. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that hypoglossal nerve stimulation has been approved by the U.S. Food and Drug Administration for the treatment of moderate to severe obstructive sleep apnea refractory to continuous positive airway pressure. However, research comparing its effectiveness to existing alternatives is lacking. Schwartz and colleagues conducted a systematic review comparing continuous positive airway pressure with mandibular advancement devices in adult patients with mild to severe obstructive sleep apnea. The authors determined that although continuous positive airway pressure improved the apnea-hypopnea index significantly more than mandibular advancement devices, continuous positive airway pressure users also were significantly less compliant with their devices compared to mandibular advancement device users. This discrepancy in usage likely contributed to results showing similar levels of improvement in the interventions across quality of life, cognitive, and functional outcomes. Overall, there is insufficient peer-reviewed evidence to support the use of hypoglossal nerve stimulation over other available therapies. Therefore, CPT codes 64568 and 0466T are not likely to be more beneficial than other treatment options.