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

Summary Reviewer 

A 38-year-old male enrollee has requested reimbursement for substance use residential treatment provided from 10/16/18 through 10/25/18. 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 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 level of care for adults. In terms of risk of harm, the records support a score of 1. There is a lack of documentation to support any current or recent suicidal ideation. In terms of functional status, the records support a score of 3. The records noted recent conflicted and withdrawn relationships with a lack of aggression. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and no serious psychiatric symptoms. In terms of level of stress of the recovery environment, the records support a score of 3. The documentation noted a stable living environment at home, but significant discord with his spouse. With regards to level of support of the recovery environment, the records support a score of 2. The patient had a stressful relationship with his spouse, but he was going to work with her in therapy. In terms of treatment and recovery history, the records support a score of 3. The patient had shown progress in treatment and expressed motivation to remain sober. It is unclear if he has maintained significant sobriety in the past. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and apparent insight into need for treatment. Thus, the patient has a composite score of 16. This score correlates with intensive outpatient treatment. The medical evidence indicates that intensive outpatient program treatment is effective for substance use. Thus, substance use residential treatment provided from 10/16/18 through 10/25/18 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The parent of a 17-year-old female enrollee has reimbursement for psychiatric residential treatment from 10/06/18 through 10/20/18. 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 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 necessary level of care for children. With regards to risk of harm, the records support a score of 1. The medical records indicate that the patient was not actively suicidal anytime during the disputed timeframe at the residential treatment center. In terms of functional status, the records support a score of 2. The patient has had some issues with level of function, but the progress notes indicate significant improvement after a period of deterioration. With regards to comorbidity, the records support a score of 2. The patient did not have active medical problems, and her psychiatric symptoms were minimal and under control. In terms of level of stress of the recovery environment, the records support a score of 2. The records noted a positive recovery environment and a stable housing situation. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment. In terms of resiliency and treatment history, the records support a score of 3. The records documented good response to a short period in the residential treatment center prior to the disputed dates of service. With regards to acceptance and engagement of the patient, the records support a score of 3. The patient participated in therapy actively, and her insight and judgment were noted to be good throughout treatment. In terms of acceptance and engagement of the parent, the records supported a score of 2. The parents worked actively and constructively with clinicians. Thus, the patient has a composite score of 17. This score correlates intensive outpatient services. In sum, psychiatric residential treatment from 10/06/18 through 10/20/18 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 22-year-old male with a history of idiopathic scoliosis. He has had extensive chiropractic care from 10/13/15 through 7/4/16 for at least 36 visits. His diagnoses are cervical and thoracic sprain, rib sprain, and muscle spasm. His treatment includes chiropractic manipulation, traction, and electrical stimulation, as well as abdominal and low back exercises. Overall, his condition was unchanged and his pain was consistently at 2/10. The patient has requested reimbursement for the chiropractic services provided from 6/13/16 through 8/13/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. The patient has a stable condition that shows no sign of improvement even with continuous extensive care. This is considered maintenance therapy and chiropractic is not superior to alternative forms of standard treatment. There is also no evidence that chiropractic care is useful in the treatment of idiopathic scoliosis. Therefore, the chiropractic treatments provided from 6/13/16 through 8/13/16 were not medically necessary. 

Based on the foregoing discussion, 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 Overturned

Summary Reviewer 1

The parent of a 15-year-old female enrollee has requested reimbursement for Prometheus Anser ADA testing performed on 10/10/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that measurement of adalimumab trough levels and antibodies is not investigational in the setting of inadequate response or loss of response to medical treatment. This approach is supported by the medical literature. However, in this case, the records indicate that testing was performed in October 2017, as a follow-up to dose intensification. At that point, the patient was feeling better and did not have clinical signs or symptoms to indicate non-response to her higher adalimumab dosing. The medical evidence does not support the services at issue in this clinical setting. Therefore, Prometheus Anser ADA testing performed on 10/10/17 was not 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 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 Overturned

Summary Reviewer 2

The parent of a 15-year-old female enrollee has requested reimbursement for Prometheus Anser ADA testing performed on 10/10/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that there is sufficient support for the services at issue in this patients case. This testing is standard in the treatment of patients with inflammatory bowel disease. This testing demonstrates the levels of drug as well as if there is antibody formation. Prometheus Anser ADA testing can guide providers in the management of the medication. If levels are low, this would explain the patients symptoms, and the medication dosage can be changed. In sum, Prometheus Anser ADA testing performed on 10/10/17 was likely to have been superior over 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

The parent of a 15-year-old female enrollee has requested reimbursement for Prometheus Anser ADA testing performed on 10/10/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. During the several months prior to the testing, the patient experienced nausea, low energy and feeling of being unwell with normal gastrointestinal symptoms. Scientific studies have suggested that drug levels and antibody testing for adalimumab is now a standard method to determine disease response to treatment. The studies also suggest that higher levels of adalimumab are associated with better therapeutic outcomes and biologic remission. In this case, the patient was having symptoms which were suggestive of relapse. Thus, it was appropriate for adalimumab levels and antibodies to be measured to determine the next steps in the management of the patients symptoms. 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 Upheld

Summary Reviewer 1

A 30-year-old female enrollee has requested reimbursement for the Anser ADA serological markers performed on 8/21/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that the Anser ADA serological markers testing performed on 8/21/15 was not likely to be more effective for this patient than other available options. There are few well controlled clinical trials to confirm that use of the adalimumab antibody testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al). In addition, it has not 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. Generally, diminished or suboptimal response to adalimumab can be managed in several ways such as shortening the interval between doses, increasing the dose, switching to a different anti-tumor necrosis factor (TNF) agent or switching to a non-anti-TNF agent based on clinical observation in lieu of Anser testing. In this case, the patient was noted to be doing well at the time her Anser study on 8/21/15. 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 2


A 30-year-old female enrollee has requested reimbursement for the Anser ADA serological markers performed on 8/21/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that in this case, Anser ADA was recommended to direct the management of the patients Crohns disease. The use of Anser ADA has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. The effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with adalimumab may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear. The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature (Karmiris, et al; Imaeda, et al). The study by Karmiris and colleagues found no direct relationship between trough serum adalimumab concentration or anti-adalimumab antibody and short-term treatment efficacy. In addition, prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. Therefore, the medical literature does not support Anser ADA as 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 30-year-old female enrollee has requested reimbursement for the Anser ADA serological markers performed on 8/21/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that the use of biologics such as Humira in Crohns disease places patients at risk for potential serious side effects. This is important when a patient loses response to Humira, which requires increasing the dose. In this case, there is concern as the disease is quite advanced and the patient had already failed several regimes. Therapeutic levels and lack of antibodies may point the treating provider toward a different medication versus another etiology. Thus, testing for antibodies identifies the subset of patients who will benefit from an increased dose. Moreover, checking for antibodies helps optimize clinical response by helping achieve a more optimal drug concentration. All told, the Anser ADA serological markers performed on 8/21/15 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 61-year-old female enrollee has requested reimbursement for magnetic resonance imaging (MRI) of the head performed on 1/05/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees head pain and traumatic injury. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. In this patients case, based on her age and symptoms, it would have been appropriate to perform cross-sectional imaging to exclude a significant brain injury.  The American College of Radiology noted although non-contrast head CT is normal in the majority of patients with minor or mild acute closed head injury, it remains the primary modality for detecting clinically relevant brain injuries in this patient population. Though non-contrast head CT has a high negative predictive value in triaging patients, this does not mean that a patient with a negative head CT does not have traumatic brain injury, and neurologically abnormal patients should be followed closely despite a negative head CT. MRI is not indicated as the initial imaging modality in the setting of minor or mild acute closed head injury. However, it may have a role in follow-up imaging. Of note, a small fresh subdural hematoma can occasionally be missed on MRI scans. There is a lack of support for an MRI in this setting, and in a general medical practice, a CT scan is appropriate. Thus, MRI of the head performed on 1/05/18 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 53-year-old male enrollee has requested authorization and coverage for Inspire upper airway stimulation system.  The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees medical condition. The physician reviewer found obstructive sleep apnea is an increasingly prevalent clinical problem with significant effects on both personal and public health.  CPAP has demonstrated excellent efficacy and low morbidity.  Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology.  There is sufficient support for the requested device in this clinical setting.  In this patient who is status post multiple procedures for sleep apnea, and who cannot tolerate CPAP or an oral appliance, implantation with a hypoglossal nerve stimulator is appropriate.  All told, the requested Inspire upper airway stimulation system is likely to be more effective than other treatment options.  Based upon the information set forth above, the requested device 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 2

A 53-year-old male enrollee has requested authorization and coverage for Inspire upper airway stimulation system.  The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees medical condition. The physician reviewer found in this patients case, the requested Inspire upper airway stimulation system is likely to be more efficacious than other treatment option.  The records document that the patient has tried multiple prior therapies to assist in the management of severe sleep disorder.  He has a long history of objective evidence of sleep apnea and meets criteria for management.  Normal management of obstructive sleep apnea is with the use of CPAP therapy.  However, this patient became intolerant of the use of this device.  This patient meets the criteria established for the implantation of the requested device.  Medical reports are now demonstrating the long-term effectiveness of this method of therapy.  Based upon the information set forth above, the requested device 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 3


A 53-year-old male enrollee has requested authorization and coverage for Inspire upper airway stimulation system.  The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees medical condition. The physician reviewer found the medical literature indicates that hypoglossal nerve stimulation for treatment of obstructive sleep apnea shows beneficial outcome with minimal adverse effect.   However, the superior effectiveness of the requested device has not been established.  Further independent outcomes data, including longer term results and effects of the device/procedure are needed before it is possible to state that hypoglossal nerve stimulation is likely to be more beneficial than standard therapies.  Thus, Inspire upper airway stimulation system is not likely to be of greater benefit than other treatment options.  Based upon the information set forth above, the requested device 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 59-year-old male enrollee has requested reimbursement for testosterone injections provided from 4/25/16 through 6/6/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees low testosterone. The physician reviewer found that this patient has low testosterone levels. Based on current medical literature, the low level and the patients symptoms were adequate to justify the three intramuscular testosterone injections. Intramuscular therapy is one way of replacing testosterone in hypogonadal men (Morley; Shoskes, et al). While topical gel therapy is preferred by most providers and patients over intramuscular injections, the latter is a standard therapeutic means of replacing testosterone in patients with low testosterone. All told, the testosterone injections provided from 4/25/16 through 6/6/16 were medically necessary for treatment of this patients low testosterone. Based on the foregoing discussions, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 31-year-old male enrollee has requested reimbursement for physical therapy provided from 9/29/17 through 2/23/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees back pain. The physician reviewer found that soft-tissue and palliative interventions, e.g., self-massage using foam rollers or massage balls, and topical treatments such as ice or heat, during the time period under review.  Although the patient had ongoing symptoms, there was no expectation of a marginally significant difference in clinical course or outcomes with the therapies in question over an independent program. Thus, physical therapy provided from 9/29/17 through 2/23/18 were 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.