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

Summary Reviewer 1

A 55-year-old male enrollee has requested reimbursement for FibroTest-ActiTest/HCV-Fibrosure test performed on 8/07/18. 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 records noted complaints of gastric pain and chronic diarrhea in the setting of acute on chronic pancreatitis of uncertain etiology. There is a lack of medical literature supporting the use of FibroTest in this setting. When liver biopsy is undesired, FibroScan demonstrates greater accuracy, sensitivity, and specificity for predicting and discriminating minimal or no fibrosis from extensive fibrosis, as well as in correlating treatment response in patients with chronic hepatitis C infection.  By comparison, serum testing combines a2-macroglobulin, haptoglobin, ?-glutamyl transpeptidase, apolipoprotein A1, alanine transaminase, and total bilirubin into a proprietary algorithm for fibrosis and inflammatory activity. The large prospective cohort study of patients with chronic hepatitis C by Patel and colleagues showed validation of the diagnostic utility of serum markers in relation to biopsy. In summary, serum and/or imaging noninvasive tests can be used for prediction of at least moderate-stage disease in a global cohort of patients with chronic hepatitis C, including the potential of high accuracy compared against liver biopsy. However, this patient does not have hepatitis C, and the appropriateness of FibroTest in this case is not support by available records. Therefore, FibroTest-ActiTest/HCV-Fibrosure test performed on 8/07/18 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 55-year-old male enrollee has requested reimbursement for FibroTest-ActiTest/HCV-Fibrosure test performed on 8/07/18. 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 patient is reported to have had abnormal liver enzyme tests. The use of FibroTest has support in current medical literature for the evaluation of and for liver disease. The alternative, liver biopsy, is invasive, with risks including bleeding, bowel perforation, and bile duct injury. It is subject to interoperator variability and sampling error. Therefore, both initial and then if needed, long-term and repeated clinical monitoring, can more safely and effectively be done with serum markers such as FibroTest rather than repeated biopsies. Over the long-term, chronic liver disease can evolve into cirrhosis, which requires specific therapy and monitoring for complications. Therefore, identification of cirrhosis with a test such as FibroTest is important to prevent complications of unidentified cirrhosis or liver disease. For these reasons, FibroTest-ActiTest/HCV-Fibrosure test performed on 8/07/18 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 55-year-old male enrollee has requested reimbursement for FibroTest-ActiTest/HCV-Fibrosure test performed on 8/07/18. 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 per the records, this patient does not have hepatitis C. In addition, there are no laboratory or imaging data to suggest the patient has advanced liver disease (i.e., cirrhosis). The test in question is used to noninvasively determine if a patient with hepatitis C has cirrhosis, which has ramifications on potential treatment choice and length of treatment. There are two general categories of noninvasive tests for fibrosis: serologic panels of tests and radiologic tests. When available, radiologic measurement of elasticity (ultrasound with transient elastography) is the preferred test. Transient elastography is the most commonly used imaging test because it is widely available and has been validated in large populations. There are several limitations to serologic markers of fibrosis. First, they typically reflect the rate of matrix turnover, not deposition, and thus tend to be more elevated when there is high inflammatory activity. By contrast, extensive matrix deposition can go undetected if there is minimal inflammation. Additionally, none of the markers are liver-specific, and concurrent sites of inflammation may contribute to serum levels. Also, serum levels are affected by clearance rates, which may be impaired either due to sinusoidal endothelial cell dysfunction or impaired biliary excretion. In this patients case, the standard of care test would be transient elastography at the time of liver ultrasound. Thus, FibroTest-ActiTest/HCV-Fibrosure test performed on 8/07/18 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The parent of a 17-year-old male enrollee has requested reimbursement for wilderness therapy program provided from 7/11/16 through 9/21/16 and from 11/3/16 through 12/27/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees behavioral health condition. The physician reviewer found that in the literature, there is lack of evidence supporting the superior treatment of wilderness therapy when compared to standard accepted therapies. In the article by Bettmann and colleagues, they reported that wilderness therapy research is significantly lacking in controlled studies. In another article by Widmer and colleagues, they noted that while some studies report benefits of wilderness therapy, caution should be exercised in the interpretation of these results. There are not enough studies that support wilderness therapy as likely to be more beneficial for treatment of the patients behavioral health condition than standard evidence based therapies. Therefore, the wilderness therapy program provided from 7/11/16 through 9/21/16 and from 11/3/16 through 12/27/16 was not likely to be have been more effective for treatment of the patients medical condition than the available standard therapies. 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 2

The parent of a 17-year-old male enrollee has requested reimbursement for wilderness therapy program provided from 7/11/16 through 9/21/16 and from 11/3/16 through 12/27/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees behavioral health condition. The physician reviewer found that there is some evidence in the medical literature that wilderness therapy is as effective as traditional psychotherapy. Prior to this patients initial admission to the wilderness therapy program on 7/11/16, the patient was noted to have worsening depressive and anxiety symptoms, difficulty with completing activities of daily living, and suicidal ideation.  He was socially withdrawn, refusing to attend school, and aggressive towards family members.  There are several published studies supporting the use of wilderness therapy in the adolescent population. Therefore, based on the support in the medical literature, the wilderness therapy program provided from 7/11/16 through 9/21/16 and from 11/3/16 through 12/27/16 was likely to have been of greater benefit than the available standard methods of treating this patients medical condition. 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 3
The parent of a 17-year-old male enrollee has requested reimbursement for wilderness therapy program provided from 7/11/16 through 9/21/16 and from 11/3/16 through 12/27/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees behavioral health condition. The physician reviewer found that the documentation provided does not support the superior efficacy of the wilderness therapy program over the available standard forms of treatment in this clinical setting. There is a lack of robust, evidence based studies to support wilderness therapy programs are superior over the standard, evidence based treatment options to address this patients diagnoses. The progress notes do not indicate that the patient was treated on any regular intervals by a psychiatrist during his stay at the wilderness program.  Key treatment goals described by the treatment program appeared vague in nature.  Treatment interventions were listed as individual and group therapy as well as various mindfulness activities and clinical evaluation. There were no treatment goals for interventions that could not have occurred in a community based treatment setting. As such, the wilderness therapy program provided from 7/11/16 through 9/21/16 and from 11/3/16 through 12/27/16 was not likely to have been superior over the standard treatment options available for treating this patient. 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 43-year-old male who has been diagnosed with generalized anxiety disorder with panic attacks. In a letter dated 1/07/19, the patient reported that he was experiencing a panic attack when he asked his colleague to call 911. The physician reviewer found that per the submitted documentation, the patient believed that he may have been experiencing a myocardial infarction due to his symptoms. He requested an immediate emergency evaluation due to his symptoms, including loss of feeling in his extremities. Based on the records, a prudent layperson would have sought immediate medical attention if given a similar symptom presentation.   The medical literature indicates that patients who have anxiety or panic attacks often have physical symptoms that may mimic a serious medical problem, such as a myocardial infarction. Emergency medical evaluation would be requested and desired by a prudent layperson who believed they were experiencing a myocardial infarction. Therefore, A0998 (ambulance response and treatment, no transport) provided on 10/27/18 were emergency services.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 57-year-old male enrollee has requested authorization and coverage for PET imaging (78816). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the management of incidentally discovered cystic pancreatic lesions depends on multiple factors, including size, morphology/location, presence of a solid component, communication with the pancreatic duct and the presence of high-risk features. Depending on these characteristics, appropriate management could include surgical resection, biopsy (if amenable) or serial follow-up imaging. In this case, the computed tomography scan could not determine if this lesion communicates with the pancreatic duct. The next appropriate imaging test would be magnetic resonance imaging/magnetic resonance cholangiopancreatography to assess ductal relationship and therefore determine follow-up and further management. The medical evidence does not support the requested services in this clinical setting at this time. Therefore, PET imaging (78816) is not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 65-year-old male has requested reimbursement for gene testing performed on 12/09/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  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 level. This helps guide the most appropriate therapy for patients taking into account their age and comorbidities because many patients will not require therapy and may be followed closely instead.  The important features to recognize are Gleason score and prostate specific antigen levels, but these are imperfect.  Thus, current biomarkers are inadequate for risk stratification, and better prognostic biomarkers are needed. The Oncotype DX prostate cancer test is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score (GPS).  The medical evidence supports the services at issue in this clinical setting in order to better stratify such patients with localized disease.  Therefore, gene testing performed on 12/09/15 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 2


A 65-year-old male has requested reimbursement for gene testing performed on 12/09/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found this patient has a low risk prostate cancer and likely has a significant life expectancy.  The medical evidence supports Oncotype DX prostate cancer testing post-biopsy for patients with very-low-risk and low-risk prostate cancer at diagnosis with 10 to 20 years life expectancy.  In this clinical setting, the services at issue were likely to be more beneficial than not performing the test and pursuing aggressive therapy.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 65-year-old male has requested reimbursement for gene testing performed on 12/09/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found the most important decision for a patient with prostate cancer is whether to undergo specific cancer treatment, or to pursue active surveillance only.  Currently, such a decision often depends on the classification of that mans cancer as to risk of progression. Using this patients pathologic parameters and prostate specific antigen, he would be seen as falling into a low-risk group.  Such a patient would seriously consider surveillance only, with no specific cancer treatment.  Beyond these clinical features, a variety of genomic assays of the individuals cancer cells have been developed, amongst which is the 17 gene assay, Oncotype DX prostate cancer testing.  The medical evidence indicates that such assays are of value in patients with low risk cancer.  Thus, gene testing performed on 12/09/15 was likely to have been more effective than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 16-year-old male enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program services provided from 6/16/18 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 behavioral health conditions. The physician reviewer found that The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) may assist in determining necessary level of care for children. With regards to risk of harm, the records support a score of 1 due to the patients lack of suicidal ideation or behaviors. In terms of functional status, the records support a score of 3. The patient has had deterioration in level of functioning in relationships with peers, adults and family. With regards to comorbidity, the records support a score of 2. The patient was noted to have substance use and several psychiatric issues. In terms of level of stress of the recovery environment, the records support a score of 3. The patient has severe problematic issues with family relationships. In terms of level of support of the recovery environment, the records support a score of 2. The patients family actively participates in treatment. With regards to resiliency and treatment history, the records support a score of 3 due to recent minimal progress in intensive outpatient program treatment. In terms of acceptance and engagement of the patient, the records support a score of 3. The patient participates somewhat in therapy, but appears non-committal. With regards to acceptance and engagement of the parents, the records support a score of 2. The parents work actively and constructively with clinicians. Thus, the patient has a composite score of 19.  This score correlates with intensive outpatient program services. Thus, intensive outpatient program services provided from 6/16/18 forward was and is medically necessary for the treatment of this patient. Therefore, the services at issue were and are 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 48-year-old male enrollee has requested reimbursement for a test used to adjust treatment for obstructive sleep apnea performed on 2/09/15.  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 the submitted documentation supports the medical necessity of the services at issue.  Per the medical records, the patient has a history of sleep apnea.  The medical notes indicate that the patient needs to be on CPAP.  The current medical evidence supports the services performed on 2/09/15.  Failure to performed the study at issue have may lead to adverse health problems for the patient.  All told, the test used to adjust treatment for obstructive sleep apnea performed on 2/09/15 was medically indicated for the treatment of this patient.  Therefore, 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 32-year-old transgender female enrollee has requested authorization and coverage for CPT codes 21137, 21209, 15824 and 15876. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. The patient has been on hormone therapy. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life. World Professional Association for Transgender Health (WPATH) states, Non-genital surgical procedures notably facial feminization surgeryare often of greater practical significance in the patients daily life than reconstruction of the genitalsThese reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. Therefore, CPT codes 21137, 21209, 15824 and 15876 are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 21-year-old male enrollee has requested reimbursement for corneal collagen crosslinking performed on 3/13/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees keratoconus. The physician reviewer found that The U.S. Food and Drug Administration (FDA) has approved this procedure. The primary purpose of crosslinking is to halt the progression of corneal thinning that occurs with conditions such as keratoconus. The procedure involves soaking the corneal stroma with riboflavin and then using ultraviolet light to create chemical bonds between collagen fibrils within the stroma. This stiffens the cornea and halts the thinning. Prior to this treatment, patients with keratoconus who failed medical treatment and whose disease continued to progress would undergo surgical management with corneal transplantation. Although this patient has been diagnosed with keratoconus, there is a lack of evidence that there has been progression of disease to warrant a crosslinking treatment. Examination notes indicate excellent visual acuity and minimal refractive error in the right eye.  In addition, there is a lack of anterior segment examination detail, keratometry, and corneal topography that would confirm the disease and its progressive nature. Therefore, corneal collagen crosslinking performed on 3/13/17 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 Overturned

Summary Reviewer 2

A 21-year-old male enrollee has requested reimbursement for corneal collagen crosslinking performed on 3/13/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees keratoconus. The physician reviewer found that based on the patients vision loss and progression, corneal collagen crosslinking was the most appropriate and effective treatment available. The medical evidence shows corneal collagen crosslinking is a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant. In this clinical setting, there is a lack of treatment option available to slow or halt disease progression. Thus, corneal collagen crosslinking performed on 3/13/17 was likely to have been of greater benefit than other treatment options. 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.