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

Summary Reviewer 2

A 39-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea. The physician reviewer found that this patient has obstructive sleep apnea and nasal obstruction. He had procedures to relieve the nasal obstruction and has continued to be unable to tolerate the CPAP device. The patient had a drug induced sleep endoscopy which showed anterior-posterior collapse. The Inspire device has been approved by the U.S. Food and Drug Administration for the treatment of obstructive sleep apnea. This patient is a candidate for the device given his body mass index (BMI) is less than 32 and he has failed CPAP therapy and nasal surgery. In sum, hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System is likely to be superior over other available treatment options. Based upon the information set forth above, the requested services are 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 39-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient has undergone surgical intervention but still has documented intolerance of CPAP therapy. Based on the records, he does meet criteria for consideration of hypoglossal nerve stimulation. Hypoglossal nerve stimulation therapy has been proven to be an effective modality for the treatment of obstructive sleep apnea in patients with tongue-based obstruction. Thus, hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System is likely to be more effective than other treatment options. Based upon the information set forth above, the requested services are 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 1

A 23-year-old female enrollee has requested reimbursement for the E0835 - RR continuous passive motion exercise device provided on 9/28/16. The Health Insurer has denied this request indicating that the device at issue is considered investigational for treatment of the enrollees status post right knee surgery. The physician reviewer found the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Fazalare and colleagues concluded that clinical evidence to support the use of CPM following knee cartilage defect surgery was lacking. The authors noted there is a need for well-conducted, high-level evidence studies to address this void in the medical literature. Similarly, Karnes and colleagues concluded that there is a paucity of clinical evidence to support broad implementation of CPM following cartilage restoration procedures. In addition, Gatewood and colleagues concluded that CPM was not warranted in post-operative protocols following arthroscopic knee surgery because of its limited effectiveness in returning knee range of motion. In this case, there is a lack of documentation showing complex regional pain syndrome, significant arthrofibrosis or tendon fibrosis, or inability to participate in active physical therapy to support the use of a CPM device over standard therapy. Therefore, the CPM exercise device provided on 9/28/16 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy in this clinical setting. Based upon the information set forth above, the device at issue was 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 23-year-old female enrollee has requested reimbursement for the E0835 - RR continuous passive motion exercise device provided on 9/28/16. The Health Insurer has denied this request indicating that the device at issue is considered investigational for treatment of the enrollees status post right knee surgery. The physician reviewer found that although continuous passive motion is not routinely recommended, the device at issue was clinically indicated for this patient. In this case, the patient presented with a chondral lesion of the medial facet of the patella and the lateral portion of the trochlea as well as an avulsion fracture increasing the likelihood of postoperative arthrofibrosis and stiffness. Continuous passive motion devices have the potential to improve the histological content as well as the rate and volume of chondrogenesis in repair tissue following chondral injury. The use of continuous passive motion can improve the outcomes of cartilage restoration procedures. Furthermore, this patients need for medial patellofemoral ligament reconstruction was associated with additional articular damage as well as an avulsion fracture which would have likely increased the possibility of arthrofibrosis after surgery. As such, the use of the continuous passive motion device starting 9/28/16 was appropriate, reasonable, and likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the device at issue was 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 3

A 23-year-old female enrollee has requested reimbursement for the E0835 - RR continuous passive motion exercise device provided on 9/28/16. The Health Insurer has denied this request indicating that the device at issue is considered investigational for treatment of the enrollees status post right knee surgery. The physician reviewer found there is a lack of medical literature supporting use of continuous passive motion exercise device following ligamentous reconstruction for patellar instability. In addition, there is limited medical literature supporting continuous passive motion exercise following any knee surgery. Moreover, the use of continuous passive motion status post total knee arthroplasty does not have clinically significant effects on active knee flexion range of motion, pain, function or quality of life to justify its routine use (Harvey, et al). Given the lack of support in the peer-reviewed literature, the E0835 - RR continuous passive motion exercise device provided on 9/28/16 was 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 device at issue was 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 Upheld

Summary Reviewer 


The parent of a 13-year-old female enrollee has requested reimbursement for the neurological evaluation and testing performed from 3/17/17 to 5/24/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees delays in gross motor, fine motor, language, and daily functioning skills. The physician reviewer found that based on the available documentation, the neuropsychological testing provided from 3/17/17 through 5/24/17 was not medically necessary for evaluation of this patients medical condition. The patient has previously been diagnosed with global developmental delay, microcephaly and ADHD combined subtype. She has been noted to have learning difficulties on previous educational psychological testing performed through the school district. The neuropsychological testing addressed her learning difficulties and ADHD, and predominantly educational difficulties rather than a medical condition. In the medical literature, Palumbo and Lynch described the utility of neuropsychological testing in addressing learning disabilities in adolescents. Pham and Riviere outlined how neuropsychological testing in children with ADHD allows implementation of assistance in an educational setting. All told, the documentation does not support the medical necessity of the neurological evaluation and testing performed from 3/17/17 to 5/24/17 for evaluation of this patients medical condition. Based on the foregoing discussion, 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 Overturned

Summary Reviewer 

The parent of a five-year-old male enrollee has requested reimbursement for air ambulance services from Los Robles Hospital to Ronald Reagan UCLA Medical Center on 5/31/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient arrived tachypneic, tachycardic, and with a low oxygen saturation. He received two doses of racemic epinephrine for croup. The records document rebound symptoms despite steroid treatment. He remained tachypneic and tachycardic, placing him at risk for respiratory failure.  Although this patient had been appropriately treated and his symptoms had improved, the on-call provider recommended that the patient be transferred in order to receive a higher level of care than could be provided at Los Robles Regional Medical Center, the pediatric intensive care unit at Ronald Reagan UCLA Medical Center. Ground transport time at that time was estimated to be 1 hour and 14 minutes. Therefore, air ambulance transport was medically appropriate in this case. Thus, air ambulance services from Los Robles Hospital to Ronald Reagan UCLA Medical Center on 5/31/18 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 46-year-old female enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee's hepatitis C virus. The physician reviewer found the proposed treatment is medically necessary and is considered the standard of care for the treatment of the patients with hepatitis C virus genotype 1a. Per the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to nonliver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure. Any decision to defer or delay treatment runs the risk of allowing a subset of patients to progress to cirrhosis and thereby increase their future risk of hepatic decompensation or hepatocellular carcinoma. As such, the requested Harvoni is medically necessary for treatment of the patients hepatitis C virus. For the reasons stated above, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


The parent of a 15-year-old male enrollee has requested reimbursement for procalcitonin testing. 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.  Maharajan and colleagues found that procalcitonin is a sensitive and specific marker in the diagnosis of septic arthritis and acute osteomyelitis.  Hunziker and colleagues concluded that serum procalcitonin is a helpful diagnostic marker supporting clinical and microbiological findings for more reliable differentiation of infectious from noninfectious causes of fever after orthopedic surgery.  The evidence-based medical peer-reviewed literature supports the use of procalcitonin level testing for orthopedic patients for differential diagnosis in multiple settings, including distinguishing bacterial infection from inflammatory conditions.  In this case, the use of procalcitonin in follow-up of a left elbow infection after surgical debridement and completion of antibiotic therapy in an adolescent patient is consistent with the literature. Therefore, procalcitonin testing was likely to have been superior over other methods of evaluation.  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 2


The parent of a 15-year-old male enrollee has requested reimbursement for procalcitonin testing. 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 this patient was status post incision and drainage of an abscess of the olecranon.  The provider has requested procalcitonin in addition to the complete blood count, sedimentation rate, and C-reactive protein to differentiate between inflammatory response and infection.  A review of the literature indicates that there is no specific advantage to using procalcitonin for this purpose. According to Mandell and colleagues, procalcitonin levels were higher in children with documented confirmed bacterial infection as compared with those with no suspicion of infection.  However, the authors noted that neither single nor serial procalcitonin measurements were able to predict the presence or absence of confirmed bacterial infection with enough certainty to be clinically useful as to recommend initiating or withholding antibiotics.  Therefore, the superior effectiveness of procalcitonin testing has not been established.  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 Upheld

Summary Reviewer 3


The parent of a 15-year-old male enrollee has requested reimbursement for procalcitonin testing. 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 level of procalcitonin in the blood rises in response to a pro-inflammatory stimulus, especially of bacterial origin.  It does not respond significantly to viral or non-infectious inflammations.  Measurement of procalcitonin can be used as a marker of severe sepsis, with a level of sensitivity of 85% and specificity of 91% in differentiating systemic inflammatory response syndrome from sepsis.  However, there is a lack of support for the services at issue in this clinical setting.  In this patients case, there was a readily accessible infection at the extensor surface of the elbow accessible to palpation and with white blood cell count monitoring and C-reactive protein monitoring. The presence of bacterial infection and the need for incision and drainage is a decision which may be made without obtaining this additional biometric.  Thus, procalcitonin level was not likely to have been of greater benefit than other modalities.  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 Upheld

Summary Reviewer 1

A 37-year-old female has requested authorization and coverage for Gammagard liquid 10% vial. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollee, who has a history of recurrent pregnancy loss.  The physician reviewer found that although this therapy has been studied extensively for this purpose, it is not considered effective or appropriate outside of experimental protocols.  Branch and colleagues noted IVIG is no more effective than heparin and low-dose aspirin in the treatment of pregnancies complicated by antiphospholipid syndrome but has not been adequately evaluated in refractory cases. Finally, pending convincing studies, IVIG is not effective and should not be used for the management of recurrent miscarriage.  Either low-dose aspirin or heparin therapy is appropriate in this clinical setting. Ata and colleagues evaluated six randomized controlled trials including 272 women. They determined a beneficial effect of IVIG in treatment of recurrent miscarriage was not observed. Given the absence of a proven mechanism of action, and the lack of a diagnostic algorithm to identify patients who are likely to benefit from such treatment, IVIG administration for treatment of recurrent miscarriage is not justified outside the context of properly designed randomized clinical trials. Therefore, Gammagard liquid 10% vial is not likely to be more efficacious than other available treatment options. Based upon the information set forth above, the requested medication 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 37-year-old female has requested authorization and coverage for Gammagard liquid 10% vial. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollee, who has a history of recurrent pregnancy loss. The physician reviewer found this patient has a complicated medical and obstetric history.  She has had a thorough work-up and multiple treatment modalities. While intravenous immunoglobulin (IVIG) seems to be an emerging and promising treatment option, the superior effectiveness of this treatment has not been established at this time. As noted in the American College of Obstetricians and Gynecologists Practice Bulletin Number 132, other therapies that have been suggested for treatment of pregnant women with antiphospholipid syndrome include corticosteroids and intravenous immunoglobulin.  However, the authors noted that because the efficacy of IVIG has not been proved in appropriately designed studies, its use is not recommended. In sum, Gammagard liquid 10% vial is not likely to be more beneficial than other available treatment methods.  Based upon the information set forth above, the requested medication 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 37-year-old female has requested authorization and coverage for Gammagard liquid 10% vial. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollee, who has a history of recurrent pregnancy loss.  The physician reviewer found that IVIG treatment has been proposed as a treatment for the diagnosis of recurrent miscarriage due to immunologic causes. The etiologies for recurrent miscarriage may include chromosomal, uterine structural, ovulatory and immune factors or combinations of these factors. The treatments for immune factors, and especially their efficacy, are currently highly controversial when assessed for the standard of care. IVIG is one of these proposed treatments. Although a few early non-randomized, uncontrolled studies may have shown modest benefit in properly characterized patients with repeated pregnancy loss, most others that have used randomized controlled methods have not. Thus, there is no clear efficacy as yet shown per the current literature. The American Society for Reproductive Medicine, in its Practice Bulletin, stated treatment with IVIG has also been proposed for unexplained pregnancy loss. However, several trials and meta-analyses concluded that IVIG is ineffective for primary recurrent pregnancy loss; thus, this treatment is not recommended. Thus, the requested Gammagard liquid 10% vial is not likely to be more effective than other treatment options. Based upon the information set forth above, the requested medication 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 1

A 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma assay performed on 4/12/18. 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 the current medical evidence has not established the superior efficacy of the services at issue. The prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add to these statistics. DecisionDx-Melanoma assay is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami and colleagues reported on 217 cases with good correlation between prognosis and DecisionDx-Melanoma assay classification, in patients undergoing sentinel node biopsy. It is not clear how the five-year DecisionDx-Melanoma assay data compares to the ten-year Balch data. Most importantly, it is not clear if DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, DecisionDx-Melanoma assay performed on 4/12/18 was not likely to have been of greater benefit than other methods of evaluating this patient.