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

Summary Reviewer 3

The parent of a 15-year-old male enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 5/13/16.  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 the patient is a 15-year-old male with Crohns disease and perianal fistulas.  On 3/02/16, he presented with epigastric pain, but no diarrhea or blood in the stool after two doses of Remicade.  Prometheus Anser IFX testing was ordered to be performed prior to the next infusion.  Per the 9/09/16 provider note, Remicade dose was increased based on the test results.  The Health Insurer has denied reimbursement for Prometheus Anser IFX testing performed on 5/13/16.  Per the Health Insurer, the services at issue were investigational for the evaluation of this patient. In this case, Anser IFX was ordered to determine Remicade level and whether antibodies to infliximab were present.  The use of Anser IFX to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease.  The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have clear Remicade levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing.  Based on clinical literature, Prometheus Anser IFX testing performed on 5/13/16 was not likely to have been more efficacious 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 25-year-old female enrollee has requested reimbursement for residential psychiatric treatment from 10/30/18 through 11/03/18. 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 the submitted documentation fails to demonstrate the medical necessity of the services at issue. By 10/30/18, the patient was not actively suicidal or homicidal. She was cognitively intact and was able to perform activities of daily living.  She was not actively psychotic or manic. The endorsement of ongoing passive suicidal thoughts (without intent) appears to be her baseline according to history provided, and no longer required monitoring on a 24/7 basis. She had continuing posttraumatic stress disorder and depressive symptoms, although this did not require 24/7 monitoring. She did not have comorbid medical conditions requiring care in a residential setting. Her medication management and any changes therein could have been performed in an ambulatory setting. She was medication compliant, cooperative, and engaged in all aspects of her treatment. She had support systems in place. Her continued treatment for depression, posttraumatic stress disorder, and any other issues, could have been safely performed at a lower level of care, including partial hospitalization program level of care. Thus, residential psychiatric treatment from 10/30/18 through 11/03/18 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 Overturned

Summary Reviewer 

The patient is a 64-year-old female with a history of chronic right knee pain due to osteoarthritis. The patient has requested reimbursement for Hyaluronan injections provided on 11/05/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that an exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patientas options were limited. She had tried and failed other conservative treatments, including bracing and medication, with the alternative being a total knee arthroplasty. Therefore, Hyaluronan injections provided on 11/05/20 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 55-year-old female enrollee has requested reimbursement for the spinal surgery and one day inpatient services provided on 1/8/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees low back pain with radiation down the right leg. The physician reviewer found that per the North American Spine Society (NASS) recommendations, this patient meets the criteria for the spinal surgery performed and one day inpatient services provided on 1/8/17. Lumbar fusion is indicated for spinal stenosis with qualifying criteria, when appropriate. These criteria include cases in which decompression will likely result in iatrogenic instability, such as foraminal stenosis, during which greater than 50% of the facet joint will be removed to adequately decompress the exiting nerve root. Per the NASS guidelines, the criteria for lumbar laminotomy include a pattern of radiculopathy/neurogenic claudication explained by imaging findings and 6-12 weeks of non-operative treatment. In this patient, the criteria have been satisfied as there is proper documentation of 6-12 weeks of non-operative treatment being performed. In addition, based upon the spinal stenosis at the foraminal level, decompression would have resulted in iatrogenic instability and therefore the requested stabilization at the L4-S1 level was medically necessary. All told, the records provided for review support the medical necessity of the spinal surgery and one day inpatient services provided on 1/8/17 for treatment of this patients low back pain and lumbar radiculopathy. 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 Upheld

Summary Reviewer 

A 28-year-old male enrollee has requested reimbursement for 30140 (submucous resection inferior turbinate) and 30465 (repair of nasal vestibular stenosis) performed on 8/31/17. 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 a diagnosis of obstructive sleep apnea requires a preliminary polysomnogram (sleep study) and a trial and failure of medical management of the sleep disorder with continuous positive airway pressure therapy. The submitted records did not document that the patient had a prior sleep study evaluation. Bilateral submucous resection (CPT code 30140) is a technique to improve the airway and has been beneficial in patients with severe obstruction noted on physical examination as well as in patients with allergic symptomatology. However, there is only modest clinical documentation that shows that this technique improves sleep apnea. Uvulopalatopharyngoplasty (CPT code 42145) may be appropriate for patients with symptoms of obstructive sleep apnea on polysomnogram who have failed adequate control with continuous positive airway pressure therapy. In this case, there was no polysomnogram available for clinical review. Therefore, 30140 (submucous resection inferior turbinate), 30465 (repair of nasal vestibular stenosis) and 42145 performed on 8/31/17 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 61-year-old female enrollee has requested authorization and coverage for Forteo pen injector 20 mcg per dose  600 mcg/2.4 mL. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees osteoporosis. The physician reviewer found that Osteoporosis is an increasingly widespread condition, affecting more than one half of patients ages 50 and older. Of these, approximately 80% are women. Fractures are the most dangerous aspect of osteoporosis (Old and Calvert). Until recently, pharmacological options for the treatment of osteoporosis have been limited to antiresorptive agents, including the oral bisphosphonates. Newer treatment agents have become available over the past few years, including Forteo, which was initially approved for treatment of osteoporosis in 2002. Forteo is a recombinant form of the biologically active component of parathyroid hormone which has been shown to increase bone mass and prevent fractures in osteoporotic bone (Drake, et al). Recent data has demonstrated that Forteo may aid in the healing of fractures and non-unions in osteoporotic patients (Babu, et al). Forteo is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture, multiple risk factors for fracture, or patients who have failed or are intolerant to other available osteoporosis therapy. Since this patient has sustained repeated fractures while on bisphosphonate therapy, the requested Forteo pen injector 20 mcg per dose  600 mcg/2.4 mL is medically necessary for treatment of her osteoporosis. Based on the foregoing discussion, the requested medication is 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 21-year-old male enrollee has requested reimbursement for mental health inpatient services provided from 9/13/18 through 9/19/18. 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 the submitted documentation supports the medical necessity of the services at issue. The American Psychiatric Association (APA) guidelines note that hospitalization is usually indicated for patients who are considered to pose a serious threat of harm to themselves or others or who are so severely disorganized or under the influence of delusions or hallucinations that they are unable to care for themselves and need constant supervision or support. All of which apply to this patient on the dates of service in question. Admission for this patient from 9/13/18 through 9/19/18 was in accordance with generally accepted standards of medical practice and clinically appropriate for the patients illness. The current medical evidence supports the services at issue in this setting. Thus, mental health inpatient services provided from 9/13/18 through 9/19/18 were medically necessary 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 33-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 4/30/15. 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 in this patients case, Anser IFX testing was used to obtain drug levels of Remicade to guide dosing.  When the level came back high on 4/30/15, the dose was lowered to every seven weeks with the plan to go to every eight weeks if the level remained high. The single clinical note does not indicate the patient had or was failing therapy.  There is a lack of controlled data to support Remicade therapy guided through serial drug level assessments.  All told, the superior efficacy of Anser IFX testing performed on 4/30/15 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 2


A 33-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 4/30/15. 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 submitted medical records fail to demonstrate the superior effectiveness of the services at issue.  Some evidence exists that low serum levels of infliximab or adalimumab and/or the presence of antibodies to infliximab or adalimumab may play a role in primary or secondary response failures.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  However, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  It has not yet been established 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.  In sum, Anser IFX testing performed on 4/30/15 was not likely to have been more efficacious 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 Upheld

Summary Reviewer 3


A 33-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 4/30/15. 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 Anser IFX test was ordered to direct the use of infliximab in this patient with Crohns disease. However, the use of Anser IFX testing to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold levels been established. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Based on the clinical literature, the services at issue were likely to be more beneficial for treatment of the patients medical condition than standard management.  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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 76-year-old female enrollee has requested reimbursement for inpatient skilled nursing sub-acute level 1 care provided from 10/30/17 through 11/2/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition status post pelvic fracture.  The physician reviewer found that based on the presented clinical records submitted for review, inpatient skilled nursing sub-acute level 1 care provided from 10/30/17 through 11/2/17 were medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, there was no documentation of a discharge plan in place as of 10/30/17. In addition, as of 10/30/17 the patient had continued mild deficits of self-care and functional mobility. As such, continued skilled services at the skilled nursing level of care were medically necessary from 10/30/17 through 11/2/17 for treatment of the patients medical condition. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 60-year-old male enrollee has requested reimbursement for positron emission tomography (PET) performed on 3/08/18. 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 that this patient exhibited biochemical failure after treatment for prostate cancer as proven by steadily rising PSA levels. Routine imaging was unremarkable. In such cases, the use of a tracer to detect prostate cancer specific tissue is the current state of the art evaluation. This determination of site of recurrence is crucial in order to direct definitive treatment. Therefore, PET performed on 3/08/18 was 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 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 60-year-old male enrollee has requested reimbursement for positron emission tomography (PET) performed on 3/08/18. 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 that based on the rising PSA levels, the patient had recurrence of his prostate cancer.  Regardless of imaging studies, rising PSA levels in a patient who has had what was felt to be definitive therapy for prostate cancer is unequivocal evidence of recurrence. If the recurrence is local, then this can be treated by external beam radiotherapy.  On the other hand, if the patient has distal metastases, the more optimal treatment is likely hormone deprivation therapy. The detection of early recurrence is often difficult.  Bone scans will be rarely positive in patients with PSA levels less than 10.  Plain x-rays will generally not detect a lesion until 50% of the bone mineralization is lost or gained (sclerotic metastases).  CT scans and MRI are dependent on the site scanned, and will only pick up gross anatomic distortions or disease.  Microscopic or small lesions will be very difficult to detect. In order to effectively cover the areas detectable by PET scanning, one would have to perform CT or MRI scans of the head, neck, chest, abdomen, and pelvis. The value of PET scanning, especially when combined with CT scans is that they depend on metabolic changes to detect abnormalities. In this patients case, the PET scan detected recurrence not appreciable by other modalities. Thus, PET performed on 3/08/18 was likely to have been superior over other available 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

A 60-year-old male enrollee has requested reimbursement for positron emission tomography (PET) performed on 3/08/18. 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 that normal surveillance for tumor recurrence for patients after radiation therapy for prostate cancer include serial serum PSA levels and digital rectal examinations. In the setting of rising PSA levels, it is necessary to determine the location and extent of the recurrent disease to guide further treatment. There are currently two FDA approved prostate-specific PET agents used in the setting of suspected recurrence, one of which is fluciclovine-18 (F-18). F-18 PET/CT has been shown to be significantly more effective than computed tomography (CT) alone. In this case of rising PSA levels in a patient with a history of prostate cancer status post radiation, multiple studies were performed, including prostate MRI and biopsies, none of which identified the site of disease recurrence. A prostate specific PET/CT examination was the next recommended test, which revealed the site of disease. Thus, PET performed on 3/08/18 was 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 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 1


A 52-year-old female enrollee has requested reimbursement for colorectal cancer screening; stool-based DNA and fecal occult hemoglobin performed on 9/16/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that according to the documentation submitted for review, this patient is unable to tolerate prep for a colonoscopy due to the triggering of migraines. The patient underwent stool-based DNA and fecal occult hemoglobin to screen for colon cancer. These tests are considered an acceptable standard of care for colon cancer screening in average risk individuals. In addition, these tests will not trigger adverse symptoms and would detect a cancerous lesion and possibly avoid a colonoscopy. Given the above, the colorectal cancer screening; stool-based DNA and fecal occult hemoglobin performed on 9/16/15 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 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.