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

Summary Reviewer 2

The patient is a 21-year-old male with a history of gastroesophageal reflux disease (GERD). The patient has been treated with pantoprazole 40 mg. Multiple esophagogastroduodenoscopies performed in 2017 showed antral erythema and Z-line irregularity without esophagitis or Barretts. A video esophagram dated 8/22/17, proved unremarkable. A Bravo pH testing dated 8/18/17 was normal. The patient has requested authorization and coverage for the esophageal sphincter augmentation device (CPT code 43284). The Health Insurer has denied this request as investigational. Based on the clinical documentation submitted for review, the esophageal sphincter augmentation device (CPT code 43284) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, testing showed a normal DeMeester score and zero symptom correlation with acid exposure, whereas esophagitis was absent visually and histologically on three serial esophagogastroduodenoscopies. LINX is indicated in GERD patients refractory to medical management. The patient does not have pathologic GERD, based on objective evidence provided. As such, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be uphel
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

The patient is a 21-year-old male with gastroesophageal reflux disease (GERD). An esophagogastroduodenoscopy (EGD) dated 6/2/17 showed localized irregularity of the mucosa in the Z-line and gastroesophageal junction and patchy erythema in the gastric fundus, body, and antrum. The digestive disease patient history questionnaire dated, 8/8/17 notes the patient has gastric reflux symptoms. Esophagogastroduodenoscopies showed antral erythema and Z-line irregularity without esophagitis or Barretts. A Bravo pH test on 8/18/17 was normal. The patient has requested authorization and coverage for the esophageal sphincter augmentation device (CPT code 43284). The Health Insurer has denied this request as investigational. The request for esophageal sphincter augmentation device (CPT code 43284) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of randomized controlled trials with long-term follow-up demonstrating that the esophageal sphincter augmentation device is safer or more effective than Nissen fundoplication or other 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). In addition, 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). The currently available peer-reviewed literature does not definitively support the conclusion that the esophageal sphincter augmentation device is likely to be more beneficial than standard treatment. The American College of Gastroenterology guidelines for the management of reflux disease states that more evidence is needed before the esophageal sphincter augmentation device can be recommended (Katz, et al).  For these reasons, the esophageal sphincter augmentation device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 49-year-old male enrollee has requested reimbursement for residential substance use disorders treatment provided from 3/27/17 through 4/22/17. 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. Modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. The records do not demonstrate that comprehensive, evidence-based services provided a less restrictive treatment setting would have been insufficient or inadequate. The patient had been engaged in hospital based care or supervised detoxification services since 3/05/17.  He was frightened by his most recent alcohol withdrawal syndrome and motivated for recovery. He had no alcohol cravings. He had a supportive girlfriend who insisted on sobriety which contributed to an environment conducive to recovery. He had not been active in chemical dependency treatment during the episode of illness.  His mental status examination had no concerning entries. He had a chronic limp but no medical or psychiatric conditions that would warrant a residential placement. All told, residential substance use disorders treatment provided from 3/27/17 through 4/22/17 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.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 55-year-old male enrollee has requested reimbursement for Oncotype DX Prostate testing performed on 1/24/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there currently are three major therapeutic approaches to the management of localized prostate cancer. These include prostatectomy, forms of radiation therapy, and active surveillance, with no specific anti-cancer treatment. Recommendations are made as to these options based on risk stratification, which involves calculating an estimate of the risk for the future development of recurrence. The patients cancer is evaluated using the pathology, prostate-specific antigen (PSA) level and clinical stage. By such a method, patients can essentially be placed into one of four major risk categories, ranging from very low, to low, to intermediate, to high risk. By such categorization, this patient would be placed in the low risk category. A further refinement of risk analysis can be performed with gene panels such as Oncotype DX Prostate testing. This is a 17-gene panel that may assist in predicting recurrence of the cancer after treatment. Increasingly, it is being used in prostate cancer. The National Comprehensive Cancer Network suggests considering such a panel for low to intermediate risk prostate cancer. Therefore, Oncotype DX Prostate testing performed on 1/24/19 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 55-year-old male enrollee has requested reimbursement for Oncotype DX Prostate testing performed on 1/24/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient has a low risk prostate cancer, and molecular profiling was considered for guiding therapy decision making. National Comprehensive Cancer Network guidelines recommend Oncotype DX tumor-based molecular assays post-biopsy for men with low or favorable intermediate risk disease. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays.  It is considered a standard of care in guiding treatment decision making. In sum, Oncotype DX Prostate testing performed on 1/24/19 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 55-year-old male enrollee has requested reimbursement for Oncotype DX Prostate testing performed on 1/24/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features, such as the grade of tumor and prostate-specific antigen (PSA) level. This helps guide the most appropriate therapy for patients taking into account their age and comorbidities, because many patients will not require therapy (i.e., surgery or radiation) and may be followed closely instead. Oncotype DX Prostate testing is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score. The current prognostic features are inadequate to make firm recommendations regarding active surveillance to patients. Oncotype DX Prostate testing is an appropriate test in this context. The National Comprehensive Cancer Network guidelines also suggest the use of this test to better stratify such patients with localized disease. Thus, Oncotype DX Prostate testing performed on 1/24/19 was likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 53-year-old female enrollee has requested authorization and coverage for durable medical equipment (Flexitouch pneumatic compression pump and leg garment).  The Health Insurer has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees lymphedema of the left leg. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the requested equipment. According to Oremus and colleagues there are several conservative (non-pharmacologic, nonsurgical) treatments that exist for secondary lymphedema, however the optimal treatment is unknown. Oremus and colleagues examined the effectiveness of conservative treatments for secondary lymphedema, as well as harms related to these treatments. The authors concluded The literature contains no evidence to suggest the most effective treatment for secondary lymphedema. According to the documentation submitted for review, the patient has been treated with CDT and use of a Medi550 Class 4 (49.0 mmHg) compression garment. However, the patient has not failed treatment with a single chamber non programmable pump which is the next of treatment for the patients medical condition. For the reasons provided, the requested equipment 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 Upheld

Summary Reviewer 


A 64-year-old male enrollee has requested reimbursement for a LifeVest provided from 6/2/14 through 9/2/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that based on the records provided for review, the patient is a 64-year-old male with a newly recognized non-ischemic cardiomyopathy and congestive heart failure. In this circumstance there is potential for recovery of left ventricular function over time with medical therapy and there was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time (more than 90 days) where continued left ventricular dysfunction (ejection fraction is less than or equal to 35%) is documented to persist in spite of appropriate treatment (Russo, et al). A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. Medical studies assessing efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction less than or equal to 35% before ventricular function has had a chance to recover have not demonstrated improved outcome (Hohnloser, et al; Steinbeck, et al). Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups (Chung, et al). At this time prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explantation.  For the reasons provided, 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 Overturned

Summary Reviewer 

The patient is a 65-year-old male with a history of history of acute respiratory failure, tracheostomy, ventilator dependent, dysphagia, seizure disorder, encephalopathy, hyperthyroidism, hyperglycemia, hyperlipidemia, polyneuropathy, and chronic obstructive pulmonary disease (COPD). The records indicate the patient was ventilator dependent with a tracheostomy and feeding tube secondary to a chronic seizure disorder status post brain surgery in March 2015. He was hospitalized in long-term care from 3/9/15 until 1/11/17. The patients provider and representatives report that the patient required skilled nursing care during this period. The patients representative has requested reimbursement for the inpatient services provided at Goldstar and Beachwood Rehabilitations Centers provided from 10/30/15 through 1/10/16 and from 4/22/16 through 1/11/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. According to the Centers for Medicare and Medicaid Services (CMS) guidelines, the medical records provided for review demonstrate that the level of care the patient received from 10/30/15 through 1/10/16 and from 4/22/16 through 1/11/17 were of a higher level than standard custodial care and were medically necessary. Throughout the records, there are numerous instances of documented skilled care and physicians orders for wound care, physical therapy as well as medical specialty consultations, laboratory and radiographic testing. This patient had a very complex, evolving combination of medical issues that required ongoing evaluation and skilled medical care. Review of the medical records indicates that the care he received during the disputed date ranges does not fit the definition of custodial care. The patient received skilled care that was medically necessary to treat his frail, evolving condition. Thus, the inpatient services provided at Goldstar and Beachwood Rehabilitations Centers provided from 10/30/15 through 1/10/16 and from 4/22/16 through 1/11/17 were medically necessary for treatment of this patients medical condition.  Based on the foregoing discussion, 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 Overturned

Summary Reviewer 


A 26-year-old female enrollee has requested reimbursement for services performed on 2/01/16 and 4/13/16 (CPT 81406 and 81415).  The Health Insurer has denied this request and reported that the services at issue were not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found that gene panels and whole exome sequencing (which both use next generation sequencing technology) for the investigation of medical complaints is a well-established clinical paradigm.  When a specific clinical diagnosis is strongly suspected, single gene testing may be appropriate.  When a category of disorder is suspected, a panel of genes that covers conditions resembling the patients presentation is appropriate.  Klein and Foroud have shown that the diagnostic yield is superior for gene panels than for single gene tests.  When no particular disorder is suggested by the patients presentation, whole exome sequencing is an appropriate next step. Information is accumulating that shows a diagnosis is made more expediently using newer genetic technologies such as exome sequencing rather than embarking upon a diagnostic odyssey that includes invasive procedures.  Recent literature shows that for neurometabolic disorders in particular, the yield of exome sequencing is high and changes clinical management in nearly half of patients.  All told, services performed on 2/01/16 and 4/13/16 (CPT 81406 and 81415) were medically indicated for the treatment of this patient.  Therefore, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 34-year-old male enrollee has requested reimbursement and prospective authorization and coverage for substance abuse residential treatment center (RTC) services provided from 9/25/16 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 alcohol dependence.   The physician reviewer found the documentation demonstrates the patient had few complaints as reported in the records provided for review as evidenced by the low CIWA scores of 1-2. The patient was not a danger to himself or others. He had no comorbid medical conditions except for the torn hip abductor for which he was awaiting surgical repair. He was anxious and had episodic depression. However, there were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant treatment at the RTC level of care. He was psychiatrically stable to the extent that he did not need a 24-hour treatment at an RTC facility to render his care from 9/25/16 forward. No new problems had arisen and there was no evidence to indicate that returning him to a less restrictive treatment environment would lead to destabilization. He was internally motivated and the psychiatry notes on 9/19/16 indicate that he was participating in treatment. He had sober supports in place. As of 9/25/16, the patient did not meet the American Society of Addiction Medicine (ASAM) clinical guidelines for RTC level of care and could have been successfully treated at an ambulatory level of care such as partial hospitalization program (PHP) or intensive outpatient program (IOP). Thus, the RTC services provided from 9/25/16 forward were not and are not medically necessary for treatment of this patients alcohol dependence. Based on the foregoing discussion, the services at issue were not and are 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 61-year-old female enrollee has requested reimbursement for Botox injections provided on 12/13/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees low back pain and spasms. The physician reviewer found that low back pain is a major cause of disability and can result in substantial morbidity. Botulinum toxin has been used successfully to alleviate pain for a number of conditions caused by muscle contractions or spasms. The medical evidence supports the use of Botox for low back pain and spasms. The study of Jazayeri and colleagues included 50 patients treated for four weeks, with 76% reporting relief. The authors found a low incidence of side effects and concluded that Botox is an effective treatment. This patient had evidence of myofascial pain and spasms with no evidence of radiculopathy or myelopathy. There was sufficient support for the requested services in this clinical setting. Therefore, Botox injections provided on 12/13/17 was likely to have been of greater benefit than other available treatment modalities. Based upon the information set forth above, the services at issue were 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 Upheld

Summary Reviewer 2

A 61-year-old female enrollee has requested reimbursement for Botox injections provided on 12/13/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees low back pain and spasms. The physician reviewer found that there is currently insufficient scientific evidence demonstrating the effectiveness of botulinum toxin in the treatment of back pain. There is a lack of high-quality studies evaluating botulinum neurotoxin injections for patients with low back pain. Among the studies that exist, there is significant heterogeneity in trial design and outcome parameters. The current body of evidence does not support the use of Botox injections to improve pain or function in patients with low back pain. There is only low-quality evidence that Botox injections are more effective than saline or corticosteroid injections or acupuncture for reducing low back pain. The present literature has yet to address the long-term benefits of Botox injections in this setting. In sum, Botox injections provided on 12/13/17 was not likely to have been of greater benefit than other treatment options. Based upon the information set forth above, the services at issue were 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 61-year-old female enrollee has requested reimbursement for Botox injections provided on 12/13/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees low back pain and spasms. The physician reviewer found that there is a lack of support for the services at issue in this patients case. Current evidence-based literature indicates that there is a lack of high-quality studies evaluating Botox injections for patients with low back pain and myofascial pain syndrome. There is a lack of clear evidence that the patient had been refractory to other treatments, as there is documented benefit with the custom heel lift and trigger point injections. Thus, Botox injections provided on 12/13/17 was not likely to have been more effective than other available treatment options. Based upon the information set forth above, the services at issue were 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.