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

Summary Reviewer 

A 34-year-old female enrollee has requested authorization and coverage for an MRI of the abdomen. 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 this patient has a genetic mutation, PRSS1, which is associated with hereditary pancreatitis, a markedly elevated risk of pancreatic cancer. It is also associated with risk of chronic pancreatitis, which causes the diarrhea and bloating symptoms, which the patient presented with. Given the increased risk of pancreatic cancer at a young age in patients with PRSS1 mutations, American Gastroenterological Association Institute guidelines for screening in patients with genetic predisposition for pancreatic cancer state that screening should be initiated at age 40. However, there is a significant rate of pancreatic cancer at young ages (8% before age 50), some of which could be missed by strict adherence to these guidelines. Separately, the patient is at risk for elevated chronic pancreatitis, and has symptoms consistent with this. Identification of chronic pancreatitis early may delay or prevent morbidity. MRI is reported to be a better diagnostic test than computed tomography scan for diagnosis, and endoscopic ultrasound is associated with higher procedural risk than magnetic resonance imaging, especially in the setting of Ehlers-Danlos syndrome. Therefore, the requested MRI of the abdomen is medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 59-year-old female enrollee has requested authorization and coverage for heart surgery to correct the heart valve using a catheter (transcatheter valve repair). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient has multiple comorbidities which make her high risk for open chest surgery, including prior extensive mantle irradiation with resulting scarring, restrictive lung disease, and a calcified porcelain aorta. There is ongoing published data supporting the safety and efficacy of transcatheter aortic valve replacement, especially in high risk or inoperable patients who require valve replacement. This patient fits into a very high risk category for open heart surgery, and this has been documented in her surgical consultations. Therefore, the requested services are likely to be of greater benefit than standard available therapy, which in this case is open heart surgery. Thus, the requested heart surgery to correct the heart valve using a catheter (transcatheter valve repair) is likely to be more effective than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 59-year-old female enrollee has requested authorization and coverage for heart surgery to correct the heart valve using a catheter (transcatheter valve repair). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested services in this clinical setting. The records noted 2-3+ moderate to moderate to severe aortic regurgitation with normal left ventricular size, normal wall thickness and normal ejection fraction on echocardiography dated 11/08/18. Therefore, the records do not support severe aortic regurgitation. In the setting of chronic severe aortic regurgitation, ventricular dilation and hypertrophy develop, which is not documented in this case. Many other conditions the patient has may also cause exertional dyspnea. There is no catheterization data to support that aortic regurgitation is a significant contributor as evidenced by elevated left ventricular end-diastolic pressure. Transcatheter aortic valve replacement has not been adequately evaluated for patients with primarily aortic regurgitation, as opposed to aortic valve stenosis. In sum, the superior efficacy of the requested heart surgery to correct the heart valve using a catheter (transcatheter valve repair) has not been established.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 59-year-old female enrollee has requested authorization and coverage for heart surgery to correct the heart valve using a catheter (transcatheter valve repair). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. In patients with symptomatic severe aortic regurgitation, surgical aortic valve replacement is the treatment of choice. Transcatheter aortic valve replacement is currently approved and indicated for individuals with severe aortic stenosis who are considered high risk for surgical valve replacement. There is no current U.S. Food and Drug Administration (FDA) approved prosthetic valve procedure using a transcatheter approach for patients with pure aortic regurgitation. The JenaValve is in the active recruitment phase for patients with severe aortic regurgitation and heart failure of New York Heart Association (NYHA) class II or higher, using transcatheter aortic valve replacement with a pericardial valve. This patient meets criteria in terms of prohibitive surgical risk and symptoms. There is a lack of treatment alternatives in this patients case. Thus, the requested heart surgery to correct the heart valve using a catheter (transcatheter valve repair) is likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 52-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found appropriate patients for the LINX Reflux Management System are those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm.  Results from early studies are encouraging.  However, at this time, the data for the LINX procedure is from observational data and not from high-quality randomized controlled trials. Without controlled data comparing it to a standard reflux operation, such as Nissen fundoplication, the superior efficacy of the requested services cannot be established.  Based upon the information set forth above, the requested services are 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 52-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the LINX device has been approved for patients with diagnosed gastroesophageal reflux disease as defined by abnormal pH testing, and who continue to have chronic gastroesophageal reflux disease symptoms despite maximal medical therapy for the treatment of reflux.  At this time, comparative studies with other anti-reflux surgeries are needed.  In this patients case, it appears she has benefited to a significant degree from acid suppression treatment, and as such cannot be considered medically refractory to acid blocker drugs. There is also room for lifestyle modification.  All told, available records do not support that the LINX device is likely to be more beneficial for treatment of the patients medical condition than available standard therapy.  Based upon the information set forth above, the requested services are 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 52-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the current medical evidence has not established the superior efficacy of the requested services.  There is a lack of randomized controlled trials comparing the LINX procedure with Nissen fundoplication or other surgical anti-reflux procedures.  Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval. The currently available peer-reviewed literature does not definitively support the conclusion that the LINX procedure is more likely to be beneficial in this case than standard treatment, surgical fundoplication.  Therefore, the requested LINX procedure is not likely to be of greater benefit than other treatment options.  Based upon the information set forth above, the requested services are 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 1

A 22-year-old male enrollee has requested reimbursement for surgical treatment of femoroacetabular impingement syndrome performed on 12/23/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees hip pain. The physician reviewer found there is limited level 3 and 4 evidence in the current evidence-based medical literature in support of the addition of capsular plication for arthroscopic treatment of femoroacetabular impingement syndrome, with additional longer term outcome studies recommended. This patient with chronic function-limiting right hip pain. Clinical examination findings were consistent with imaging and radiographic evidence of a right hip labral tear and femoroacetabular impingement syndrome. There was no documentation of hip instability on clinical examination. He underwent right hip arthroscopic labral repair, acetabular rim trimming, femoral osteochondroplasty, and capsular plication on 12/23/15. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of capsular plication for the treatment of femoroacetabular impingement syndrome. Therefore, surgical treatment of femoroacetabular impingement syndrome performed on 12/23/15 was not likely to have been superior over other available treatment alternatives. 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 22-year-old male enrollee has requested reimbursement for surgical treatment of femoroacetabular impingement syndrome performed on 12/23/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees hip pain. The physician reviewer found that femoral and/or acetabular bone can develop rough edges or an irregular shape, which can subsequently impinge against the bone and soft tissues, causing tendon/labral/capsular damage. It has been theorized that by shaving and contouring the bony prominences, surgeons might protect patients from further injury and prevent additional arthritic progression. Short-term results showed that individuals with greater than 2 mm of joint space might expect some improvement in pain and function after hip arthroscopy for femoroacetabular impingement. Degen and colleagues reported that a cohort of 86 competitive baseball players undergoing femoroacetabular impingement surgery had 88% return-to-sport rate. In this case, the patient had insidious onset of symptoms for greater than six months prior to surgical treatment. There is documented evidence of a failed conservative management program to include intraarticular corticosteroid injection, activity modification and a formal course of physical therapy. The records documents well-preserved joint space and radiographic findings consistent with femoroacetabular impingement. While the literature is lacking high-quality randomized controlled trials, there is a propensity of studies consistently demonstrating benefit in this clinical setting (young age, no advanced degenerative changes on imaging and classic physical examination findings with corroborating imaging). Except for hip arthroplasty, which should be the option of last resort in a patient of this age, there was a lack of other reasonable treatment interventions which have been shown to be efficacious. There is sufficient support for the services at issue in this patients case. In sum, surgical treatment of femoroacetabular impingement syndrome performed on 12/23/15 was likely to have been more effective than other treatment alternatives. 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 Overturned

Summary Reviewer 3

A 22-year-old male enrollee has requested reimbursement for surgical treatment of femoroacetabular impingement syndrome performed on 12/23/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees hip pain.The physician reviewer found that surgical treatment of symptomatic femoroacetabular impingement aims to improve symptoms and potentially delay hip osteoarthritis and prevent the need for a possible total hip arthroplasty. Hip arthroscopy and open surgical hip dislocations are the two most common surgical approaches used for this condition.  The arthroscopic procedure avoids some of the complications of open surgery, but both approaches result in over 75% good to excellent results.  Femoroacetabular impingement may be of the cam or pincer-type, or it may be mixed as in this case.  Surgery is recommended when the degenerative changes are mild or absent, as in this case with documented failure of conservative treatment. The current medical literature indicates that arthroscopic surgery for femoroacetabular impingement has a known excellent outcome in the majority of individuals. Thus, surgical treatment of femoroacetabular impingement syndrome performed on 12/23/15 was likely to have been of greater benefit than other treatment alternatives. 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 
This patient is a 44-year-old female who presented to her provider on 3/12/21. The records noted that is 5 feet 2 inches tall and weighed 165.7 pounds, resulting in a body mass index of 30.31 kg/m2. The patient has requested authorization and coverage for laparoscopy, surgical, gastric restrictive procedure, with gastric bypass and Roux-en-Y gastroenterostomy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Although the patient may benefit from conversion to gastric bypass for treatment of severe refractory gastroesophageal reflux disease in the setting of a prior Lap-band with hiatal hernia and esophageal dysmotility, additional documentation is needed. The poor esophageal motility would make her a poor candidate for either a LINX or standard Nissen fundoplication. However, the patient should still undergo a comprehensive multidisciplinary evaluation for the subsequent dietary and lifestyle changes unique to gastric bypass regardless of the primary indication. Although a brief dietary note was provided with standard dietary handouts, the records do not document a behavioral evaluation. Therefore, a multidisciplinary evaluation has not been completed. Therefore, the requested laparoscopy, surgical, gastric restrictive procedure, with gastric bypass and Roux-en-Y gastroenterostomy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 65-year-old male enrollee has requested authorization and coverage for Rytary. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees Parkinsons disease. The physician reviewer found that the submitted documentation fails to support the medical necessity for the requested medication. While Rytary is a medication that is commonly used for the treatment of patients with Parkinsons disease, it is prescribed after the patient has tried and failed extended release formulations. The documentation provided do not demonstrate that this has been administered in this patient.  The patient has not been placed on extended release formulations of carbidopa/levodopa. As such, it would be appropriate for the patient to try the extended release formulations prior to being started on Rytary. Accordingly, Rytary is not currently medically necessary for treatment of this patient.  Therefore, for the reasons stated above, the requested medication 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 63-year-old male enrollee has requested reimbursement for the prostate ablation performed on 10/24/17. The Health Insurer has denied this request indicating that the procedure at issue was not medically necessary for treatment of the enrollees prostate cancer. The physician reviewer found that HIFU consists of focused ultrasound waves, emitted from a transducer, that cause tissue damage by mechanical and thermal effects as well as by cavitation. The goal of HIFU is to heat malignant tissues above 65C so that they are destroyed by coagulative necrosis. HIFU has been increasingly been used for treatment of localized prostate cancer over the last decade. However, there is a paucity of controlled trials available for analysis, and currently no long-term survival data are available. In addition, the National comprehensive Cancer Network (NCCN) guideline indicates that HIFU warrants further study, but has not been demonstrated to result in long-term improved health outcomes. Moreover, the National Cancer Institute does not list HIFU as one of the seven standard treatments for treatment of prostate cancer. Furthermore, the American Urological Association (AUA), American Society of Radiation Oncology (ASTRO), and SUO guideline report that providers should inform low-risk prostate cancer patients who are considering focal therapy or high intensity focused ultrasound (HIFU) that these interventions are not standard care options because comparative outcome evidence is lacking. All told, the prostate ablation performed on 10/24/17 was not medically necessary for treatment of this patients prostate cancer. Based on the foregoing discussion, the procedure at issue was 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 


A 60-year-old female enrollee has requested reimbursement for inpatient services provided from 6/21/17 through 6/26/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees non-ST-elevation myocardial infarction. The physician reviewer found that this patient presented with a non-ST segment myocardial infarction on 6/19/17, and she was treated with medication including intravenous heparin. In this setting, it is standard of practice to treat with intravenous heparin for 48 to 72 hours. Since the patient was on intravenous heparin for at least part of the day on 6/21/17, she could not have been safely discharged on that day.  However, since she remained clinically stable without recurrent chest discomfort or other evidence of ongoing ischemia on 6/22/17, about 24 hours after heparin was discontinued, it would have been medically safe to discharge the patient on this date, to return for coronary bypass surgery once dental abscess and nickel allergy had been sufficiently evaluated and treated. The records do not support the medical necessity for continued inpatient care beyond 6/22/17. All told, inpatient services provided from 6/21/17 through 6/22/17 were medically necessary for the treatment of this patient, but not thereafter. Therefore, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of an 11-year-old male enrollee has requested authorization and coverage for Epidiolex Solution (cannabidiol). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees intractable epilepsy. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. This patient has medically refractory epilepsy, having been tried on multiple anticonvulsant medications without obtaining seizure control. He has structural brain abnormalities that increase his risk of having intractable epilepsy. Silvestro and colleagues noted, Cannabidiol (CBD) is one of the cannabinoids with non-psychotropic action, extracted from Cannabis sativa. CBD is a terpenophenol and it has received a great scientific interest thanks to its medical applications. This compound showed efficacy as anti-seizure, antipsychotic, neuroprotective, antidepressant and anxiolytic. The neuroprotective activity appears linked to its excellent anti-inflammatory and antioxidant properties. The authors stated, The results of scientific studies obtained so far for the use of CBD in clinical applications could represent hope for patients who are resistant to all conventional anti-epileptic drugs. Epidiolex has been demonstrated to be an effective long-term treatment option in Lennox-Gastaut syndrome and Dravet syndrome, two forms of intractable generalized epilepsy syndromes in children, and is approved by the U.S. Food and Drug Administration (FDA) for those conditions. The drug does not have biological specificity for these two conditions, however. OConnell and colleagues noted that open-label studies with 100mg/ml CBD (Epidiolex, GW Pharmaceuticals) have provided additional evidence of its efficacy along with an adequate safety profile (including certain drug interactions) in children and young adults with a spectrum of treatment resistant epilepsies. There is sufficient support for the requested medication in this clinical setting. Therefore, Epidiolex solution (cannabidiol) is medically necessary for the treatment of this patient.