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

Summary Reviewer 1

A 45-year-old female enrollee has requested reimbursement and prospective authorization and coverage for Gamunex-C from 7/01/21 forward. The Health Insurer has denied this request and reported that the medication at issue was and is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that standard treatment of small fiber neuropathy is dependent on the underlying etiology as well as treatment of associated neuropathic pain, which can include several different classes of medications. In small fiber neuropathy, current neuropathic pain treatment options are generally insufficient to relieve the pain substantially. Small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions. Intravenous immunoglobulin (IVIG) is a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy.
In a retrospective study by Liu and colleagues, 55 patients with objectively confirmed small fiber polyneuropathy (SFPN) attributed to autoimmunity received IVIG for more than three months. The proportion of autonomic function tests (AFT) interpreted as indicating SFPN dropped from 89% at baseline to 55%. Sweat production normalized, and the other four domains all trended toward improvement. Overall, 74% of patients rated themselves aimproveda, and their neurologists labeled 77% as aIVIG respondersa. The authors concluded that the results provide Class IV evidence suggesting that IVIG is safe and effective for rigorously selected SFPN patients with apparent autoimmune causality.
A review article by Oaklander reviewed various studies regarding immunotherapy for distal SFPN. The authors noted, aThese reports also provide a rationale for treating carefully selected patients with immunomodulatory therapies. Candidates should have symptoms consistent with SFPN, objective confirmation of diagnosis, exclusion of other causes, failure to improve with symptom management, and, ideally, serologic markers of immunity/inflammation.a In this case, the patient has small fiber polyneuropathy and an autoimmune condition. Her clinical symptoms have improved with the use of IVIG. Based on the studies noted above, patients with autoimmune small fiber neuropathy may improve clinically with IVIG. Therefore, Gamunex-C from 7/01/21 forward was and is likely to be more beneficial for the treatment of this patient than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 45-year-old female enrollee has requested reimbursement and prospective authorization and coverage for Gamunex-C from 7/01/21 forward. The Health Insurer has denied this request and reported that the medication at issue was and is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is a lack of support for Gamunex-C in this clinical setting. Damages nerves causing neuropathy can cause a wide constellation of symptoms, as they are involved in both somatic and autonomic processes. Pain is a common complaint with neuropathies as well as other forms of paresthesia. Causes of neuropathies vary from diabetes, celiac disease, hepatitis, restless leg syndrome, neurotoxic drugs, paraneoplastic syndromes, Sjogrenas syndrome, and lupus, to name a few. While there is evidence to support the possibility of efficacy of IVIG in neuropathies, it is limited at best and studies call for further investigation into its use. Therefore, Gamunex-C from 7/01/21 forward was not and is not likely to be more beneficial for the treatment of this patient than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 45-year-old female enrollee has requested reimbursement and prospective authorization and coverage for Gamunex-C from 7/01/21 forward. The Health Insurer has denied this request and reported that the medication at issue was and is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the polyneuropathies involve widespread damage to the bodyas peripheral nerves. Small fiber polyneuropathy (SFPN), also known as small fiber neuropathy, refers to those polyneuropathies that preferentially affect peripheral neurons with the thinnest axons. Small fiber neurons multifunctionality explains why SFPN increases risk of multiple symptoms. The most common are chronic widespread pain and/or itch, postural hypotension and/or tachycardia (POTS), nausea, constipation and/or diarrhea, disordered sweating, followed by urological and sexual dysfunction. Many studies have shown that autoimmunity and inflammation play a great role in SFPN. Treatments for these involve high dose steroids, IVIG or plasma exchange. Steroids carry significant side effects. Therefore, over the years, IVIG has been assuming a more important role. Cessation of the IVIG treatment in this patient could be detrimental to her health and quality of life. Therefore, Gamunex-C from 7/01/21 forward was and is likely to be more beneficial for the treatment of this patient than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 60-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/10/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that this patient had an early stage melanoma. Commercially available gene expression profiling (GEP) tests are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear whether these tests provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariable nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. Newer prognostic molecular techniques should not replace standard staging procedures.  In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. This test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Therefore, DecisionDx-Melanoma testing performed on 10/10/19 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 60-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/10/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individualas melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear if the assay can be used to make clinical decisions. All told, DecisionDx-Melanoma testing performed on 10/10/19 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 60-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/10/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. The test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing performed on 10/10/19 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a nine-year-old female enrollee has requested reimbursement and prospective authorization and coverage for 20 hours per week of applied behavioral analysis (ABA) therapy provided from 9/28/17 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 that the request for 20 hours per week of ABA therapy provided from 9/28/17 forward was not and is not medically necessary for treatment of the patients autism spectrum disorder. According to the documentation submitted for review, the patient is documented as making progress with her goals. The Health Insurer authorized 16 hours per week of ABA therapy is medically appropriate and adequate in this clinical setting. In sum, there is a lack of clinical documentation supporting the request for 20 hours per week of direct ABA services for treatment of the patients autism spectrum disorder. Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 56-year-old male enrollee has requested reimbursement for ipilimumab (J9228) and pembrolizumab (J9271) injections administered on 7/19/16 and 9/13/16. The Health Insurer has denied this request indicating that the medications at issue were not medically necessary for treatment of the enrollees prostate cancer. The physician reviewer found that there is a lack of support in the medical literature for the medications at issue used in this clinical setting. Ipilimumab and pembrolizumab are not considered a standard treatment for prostate cancer either systemically or as localized therapy. They are not U.S. Food and Drug Administration approved and are not supported by major drug compendia or the medical literature. Yervoy and Keytruda are the ongoing subject of clinical trials that have not yet reached beyond phase I and II trials. As such, ipilimumab (J9228) and pembrolizumab (J9271) injections administered on 7/19/16 and 9/13/16 were not medically necessary for the treatment of this patients medical condition. Therefore, based on the above, the medications 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 
The patient is a 24-year-old female with a medical history significant for congenital central hypoventilation syndrome and subsequent cardiac arrhythmia, requiring pacemaker placement. The patient has requested authorization and coverage for a home ventilator. The Health Insurer has denied this request and reported that the requested equipment is not medically necessary for the treatment of this patient. The physician reviewer found that congenital central hypoventilation syndrome is an extremely rare disorder. These patients lack the expected arousal response to hypoxemia and hypercarbia during sleep, and in extreme cases, during wakefulness as well. They do not respond like typical patients to exercise or infection, either because they do not perceive hypoxemia or hypercarbia. They are at long-term risk for cardiac abnormalities and pulmonary hypertension. Management of these patients involves and requires ventilatory support with non-invasive or tracheostomy-associated mechanical ventilation. This is the standard of care and it is life-preserving and lifesaving in this very complicated yet small patient population. Therefore, the requested home ventilator is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 40-year-old transgender female who is seeking facial feminization surgery. Per the Health Insurer, the requested services are not medically necessary for the treatment of the patientas medical condition. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. Facial feminization surgery is a common treatment for gender dysphoria. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, aimproved mental health-related quality of life.a The World Professional Association for Transgender Health (WPATH) Position Statement on Medical Necessity of Treatment states, aNon-genital surgical proceduresa notably facial feminization surgeryaare often of greater practical significance in the patientas daily life than reconstruction of the genitalsaThese reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition.a Therefore, the requested facial feminization surgery is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer
 
The patient is a 20-year-old male with a history of opioid use disorder, amphetamine use disorder, sedative, hypnotic, or anxiolytic use disorder, major depressive disorder, and generalized anxiety disorder. The patients onset of substance use was at age 15 with opiates, benzodiazepines, cannabis, and amphetamines. He has a history of two prior residential admissions and an intensive outpatient program, which were quickly followed by relapse upon discharge.  Prior to the admission in question, the patient reported using half a gram of heroin and unknown amount of cannabis daily for three to four months. He was admitted to a residential treatment program on 4/25/17 and discharged on 7/24/17. During admission, the patient participated in individual, group, family therapy and medication management. The patient has requested reimbursement for substance abuse residential treatment provided from 5/22/17 through 7/24/17. The Health Insurer denied this request and reported that the services at issue were not medically necessary for treatment of this patients medical condition. This denial is the subject of this appeal and determination. The submitted documentation supports the services at issue in this clinical setting. Per the provided documentation, by 5/22/17, the patient still remained symptomatic. The patient was documented as having strong urges to use, irritability, daily mood swings, anxiety, restlessness, and difficulty with sleep. He was described as being somewhat disengaged in the program.  The patient was noted to have limited education and was homeless due to being kicked out of his sober living house. The American Society of Addiction Medication (ASAM) Criteria, a set of objective guidelines used by clinicians to assist with treatment planning, advocates for service intensity provided in the least intensive environment but safe treatment setting (Mee-Lee and Shulman). The guidelines also recommend that length of service should be determined by the patients progress with his treatment plan as determined by the patient and treatment providers. The medical research indicate that individuals with substance use disorders often need longer term care due to the relapsing and chronic nature of the disorders (Manuel, 2017). By 5/22/17, this patients records did not demonstrate that he was ready to be discharged to a lower level of care. Residential substance abuse treatment has been shown to improve substance use outcomes (Manuel, et al, 2017).  Based on current medical literature, ASAM criteria, and the patients documented clinical history, this patients admission to the residential level of care from 5/22/17 through 7/24/17 was medically necessary (Mee-Lee and Shulman; Ali et al; Gray and Squeglia; Manuel, et al).
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 42-year-old female who has been diagnosed with myasthenia gravis. Per the submitted documentation, this causes difficulty with breathing and swallowing.  The physician reviewer found that the 2012 American Academy of Neurology guidelines for intravenous immunoglobulin in the treatment of neuromuscular disorders recommends that IVIG should be considered in the treatment of myasthenia gravis. This recommendation was based on studies involving primarily moderately or severely affected patients. A retrospective study by Sorgun and colleagues investigated thirteen patients who had displayed an inadequate clinical response to immunosuppressive treatments, or who were not appropriate for immunosuppressive treatment due to the age factor and thus were given regular IVIG therapy. The number and severity of the attacks were decreased in all patients. The authors concluded, IVIG can produce repeated beneficial effects in patients with myasthenia gravis and may be useful as an adjunct in the management of myasthenia gravis. IVIG has minimal adverse effects and ability to reduce corticosteroid dose. In this case, the patient has severe myasthenia gravis that affects her breathing and swallowing.  She had an inadequate clinical response to other immunosuppressive treatments and has osteoporosis, which could be exacerbated by the use of corticosteroids. Treatment with weekly IVIG has improved her symptoms. Based on the studies noted above, IVIG is a valid modality in this patient because it has decreased the number and severity of exacerbations and has allowed a decrease in her corticosteroid dosage. For these reasons, IVIG 500 mg twice per week is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 49-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health outpatient treatment provided from 4/19/18 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, a mental disorder is defined as a syndrome characterized by clinically significant disturbance in an individuals cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. According to the clinical information presented for this review, this definition of a mental disorder is not met per the documentation. The records do not document the medical necessity of the services at issue due to overall lack of support for the presence of a mental illness. Therefore, mental health outpatient services from 4/19/18 forward were not and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 37-year-old male enrollee has requested reimbursement for single-photon emission computed tomography (SPECT) imaging (CPT 78607) provided on 2/22/17 and 2/23/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees behavioral health conditions.  The physician reviewer found that SPECT is a sophisticated nuclear medicine study that examines blood flow in the brain with the assistance of a radioactive tracer that is introduced to the patients body.  Brain activity demands blood flow, so it is postulated that SPECT can provide information regarding hyperactive, suboptimal or normal functionality of specific brain structures and regions. Advances in neuroimaging techniques, such as SPECT, represent an exciting, and potentially useful, expansion of the collective knowledge base. However, the technology is still in its infancy, and meaningful correlation between clinical diagnoses and specific brain activity patterns does not yet exist. Additionally, the documentation did not indicate that first-line strategies for the treatment of mood and anxiety disorders had been exhausted. Further, it was noted that the patient had urges to associate with other women only when he drinks, but there was no discussion about the possibility of an alcohol use disorder or interventions to ameliorate that precipitating factor. In sum, considering the relevant peer-reviewed literature and current practice standards in the United States, at this point in time, SPECT is not a standard diagnostic intervention.  Further, it has not been established that the disputed neuroimaging yielded information that significantly influenced treatment decisions, improved the patients condition, prevented a more serious episode of illness or reduced the psychiatric morbidity. Thus, SPECT imaging (CPT 78607) provided on 2/22/17 and 2/23/17 was not medically necessary for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 39-year-old male enrollee has requested reimbursement for the sleep study performed on 3/30/17. The Health Insurer has denied this request indicating that the service at issue was not medically necessary for evaluation of the enrollees obstructive sleep apnea (OSA). The physician reviewer found based on the medical literature and the presented clinical records submitted for review, the sleep study performed on 3/30/17 was not medically necessary for evaluation of the patients medical condition. In this case, the patient has no documentation demonstrating lung disease, heart disease or neuromuscular disease. There is no documentation of dementia or impairment. In sum, there is a lack of objective documentation provided for review that supports the medical necessity of a facility based sleep study. The sleep study could have been performed in a home setting. For the reasons provided, the sleep study performed on 3/30/17 was not medically necessary for evaluation of the patients medical condition. Therefore, the service at issue was not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.