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

Summary Reviewer 2

A 24-year-old female enrollee has requested reimbursement for 83993 (fecal calprotectin) provided on 1/30/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of diarrhea. The physician reviewer found that persistent disease activity is associated with a poor prognosis in inflammatory bowel disease. Therefore, monitoring of patients with intent to suppress subclinical inflammation has emerged as a reasonable community-standard treatment goal. As endoscopic monitoring is invasive, identification of valid markers of disease activity has been a priority. Fecal calprotectin testing is commonly used in clinical practice to differentiate between non-organic and inflammatory intestinal disorders, especially to identify inflammatory bowel disease. Fecal calprotectin may also be useful to monitor patients with inflammatory bowel disease under treatment and to predict the risk of recurrence of active disease prior to clinical relapse. In this patients case, the provider noted that fecal calprotectin testing was recommended to distinguish inflammatory from noninflammatory diarrhea. However, prior stool and imaging studies were negative, and inflammatory bowel disease was an unlikely possibility based on the history. While fecal calprotectin as commonly employed in clinical practice may have value in irritable bowel disease patients, or even in cases of diagnostic uncertainty, this testing was not supported in this patients case. In sum, the superior efficacy of 83993 (fecal calprotectin) provided on 1/30/18 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

A 24-year-old female enrollee has requested reimbursement for 83993 (fecal calprotectin) provided on 1/30/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of diarrhea. The physician reviewer found that Fecal calprotectin is often ordered to determine whether inflammation (disease activity), such as inflammatory bowel disease, is present as a cause for gastrointestinal symptoms such as diarrhea. A meta-analysis by Van Rheenen and colleagues found that up to 11% of adults with inflammatory bowel disease may be misclassified as having noninflammatory disease, such as irritable bowel syndrome. As a rule-out test, this is not sufficient. The use of calprotectin to diagnose change in bowel habits has not been subsequently accepted. The impact of this testing on management and its appropriateness in guiding therapy decisions in patients with unexplained diarrhea has not been demonstrated. The findings can be redundant with standard methods of diagnosis, such as colonoscopy or sigmoidoscopy, or other serum markers of inflammation. Guidelines on the diagnosis and management of diarrhea do not recommend calprotectin as part of the investigation. Furthermore, clinical studies do not support a standardized action, such as empiric use of antibiotics or empiric therapy for inflammatory bowel disease, for a positive result. For these reasons, 83993 (fecal calprotectin) provided on 1/30/18 was not 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 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 58-year-old female enrollee has requested authorization and coverage for an electric hospital bed (E0265). The Health Insurer has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollee, who has been diagnosed with muscle weakness and reduced mobility. The physician reviewer found that the patient has a history of alcohol abuse and liver cirrhosis, conditions associated with encephalopathy due to multiple mechanisms of action. The patient also had muscle weakness and significant mobility impairments. She was requiring total assistance for transfers by mechanical lift transfer device. She had positioning needs due to her respiratory condition, gastrostomy tube feeds, pressure injury and susceptibility for skin and soft tissue breakdown. These mobility needs could have been met with a semi-electric hospital bed with an appropriate mattress surface. A total electric hospital bed also includes electric height adjustment, which could be necessary for individuals who require this feature for independent transfers into and out of the bed.  In the current case, this feature was obviated by the patients use of a mechanical lift device for dependent transfers. Electric height adjustment on a hospital bed is otherwise considered a convenience feature. Thus, the requested electric hospital bed (E0265) is not medically necessary for the treatment of this patient. Therefore, the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 44-year-old female enrollee has requested authorization and coverage for HP Acthar Gel 80. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. There is a lack of randomized, double-blinded, placebo-controlled studies in support of Acthar for systemic lupus erythematosus. The current evidence consists of small reports. The study by Levine involved a small group of patients with myositis that responded favorably to Acthar. Although this is encouraging, it is not conclusive in that group of patients. The study by Fiechtner and Montroy included just ten patients, and patients were followed only over a 28-day period. This is an inadequate study to base approval of this medication for this patient. Pegrams study is inadequate, as it was a retrospective evaluation of four woman with lupus who were followed for 1.5, 3.5, 6 and 9 months each. At this time, the medical necessity of the requested medication has not been established. Therefore, HP Acthar Gel 80 unit/ml vial is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 60-year-old female who has been diagnosed with major depressive disorder, recurrent, moderate.The patient has requested authorization and coverage for brand name Wellbutrin 150 mg, brand name Wellbutrin 300 mg and brand name Prozac 20 mg. The Health Insurer has denied this request and reported that the requested medications are not medically necessary for the treatment of this patient.The physician reviewer found that given this patients stability, it is within the standard of care to maintain her on brand name medications as she poses a risk of decompensation should she be switched to generics. She has tried generics in the past and reports that she could not tolerate the fillers in the medications and that the generics were not effective in treating her depression. Some studies have demonstrated that brand name medications exhibited more protective effects on psychiatric hospitalization for depressive patients, and that the efficacy of generics versus brand name is not equal. Several different companies may make the same generic drug, but they might use different filler ingredients, and this they may have slightly different rates of absorption or cause different side effects. With somewhat older antidepressants, such as fluoxetine (Prozac), several different manufacturers make the generic antidepressants, each using different non-active ingredients. Thus, each generic brand may have slightly different effects. The current medical evidence supports the requested medications in this clinical setting. Therefore, brand name Wellbutrin 150 mg, brand name Wellbutrin 300 mg and brand name Prozac 20 mg are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 60-year-old female enrollee has requested authorization and coverage for Taltz. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriatic arthritis. The physician reviewer found that this patient failed therapy with Celebrex, methotrexate and Stelara, and she did not tolerate Enbrel and Humira. The records do not document that she has tried and failed or has a contraindication the Health Insurers preferred therapy, Cosentyx (secukinumab). Per Patel and colleagues, based on available evidence, secukinumab offers an effective new addition to the psoriatic arthritis treatment repository. Mease and colleagues noted subcutaneous secukinumab provided sustained improvements in the signs and symptoms, quality of life and physical function of patients with active psoriatic arthritis with low rate of radiographic disease progression through three years. Taltz has not been demonstrated to be superior to Cosentyx in terms of efficacy or safety. Thus, Taltz is not medically necessary for the treatment of this patient. Therefore, 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 57-year-old male enrollee has requested reimbursement for CT maxillofacial without contrast material provided on 7/29/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to support the medical necessity of the services at issue. The patient underwent resection of a calcifying epithelial odontogenic tumor in February 2019. The notes indicated that a final obturator would be fabricated in October 2019. There is no documentation to support the need for a repeat CT scan in July 2019. Patients with calcifying epithelial odontogenic tumor do require lengthy follow-up, as recurrences have been reported as late as 31 years status post surgery. In this patients case, the records do not demonstrate the need for the CT scan in July 2019. Therefore, CT maxillofacial without contract material provided on 7/29/19 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

An 18-year-old female enrollee has requested reimbursement for psychiatric residential treatment provided from 2/17/20 through 3/01/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that with regard to risk of harm, the records support a score of 4. There was a serious risk of harm, due to suicidal ideation with a recent history of overdose, and the patients stated inability to keep herself safe at home. Additionally, there was recent excessive substance use. In terms of functional status, the records support a score of 3. The patient had moderate functional impairment, due to conflict with her mother and declining grades. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity, due to alcohol abuse, post-traumatic stress disorder, and depression as well as a recent concussion. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to sexual assault and a recent change in school. With regard to level of environmental support, the records support a score of 2. Her parents participated in treatment. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment, due to continued symptoms despite outpatient treatment, inpatient hospitalization, and partial hospitalization program and intensive outpatient program treatment. With regard to acceptance and engagement, the records support a score of 2. The patient had initial difficulty being open and honest with treatment providers about the extent of her symptoms. Thus, the patient has a composite score of 21. This score supports medically monitored residence-based services, due to serious risk of self-harm and environmental stress. The submitted documentation supports the services at issue in this clinical setting. Therefore, psychiatric residential treatment provided from 2/17/20 through 3/01/20 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The parent of an 11-year-old female enrollee has requested reimbursement for the FirstStep PLUS test provided on 11/23/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees severe attention deficit hyperactivity disorder (ADHD) and developmental delays. The physician reviewer found that the clinical utility of CMA is well established, and is now considered first-line genetic tests for patients with developmental delays and autism spectrum disorders according to the American Academy of Pediatrics, the American College of Medical Genetics, the American College of Neurology and the Child Neurology Society (Schaefer, et al; Moeschler, et al; Shevell, et al; Shen, et al). In a study by Coulter and colleagues, a retrospective chart review of CMA testing was performed on patients with developmental delay, intellectual disability, autism spectrum disorders and congenital anomalies. Findings in this study demonstrated that CMA results influenced medical care by in the majority of patients by precipitating medical referrals, diagnostic imaging, or specific laboratory testing, supporting the use of CMA as a clinically useful diagnostic test. It is for these reasons, that the FirstStep PLUS test provided on 11/23/16 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 testing at issue was 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

The parent of an 11-year-old female enrollee has requested reimbursement for the FirstStep PLUS test provided on 11/23/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees severe attention deficit hyperactivity disorder (ADHD) and developmental delays. The physician reviewer found that array-based comparative genomic hybridization or chromosomal microarray (CMA) has become the standard of care to evaluate children with developmental delay, intellectual disability, autism spectrum disorders or congenital anomalies. This patient meets the criteria established for CMA use given the documentation of intellectual disability. In addition, the patients positive family history provides additional support for this testing. In the medical literature, Henderson and colleagues reported that 12.7% of patients meeting referral criteria had a pathogenic copy number variant identified on microarray, and that half of those results influenced management including pharmacological treatment, cancer-related screening or exclusion of screening, identifying contraindications, and referrals for further evaluation. Riggs and colleagues demonstrated that 7% of microarray results impact clinical management, a rate which is similar to other genetic tests. Data have now emerged showing that actionable findings from CMA justify its use. All told, the FirstStep PLUS test provided on 11/23/16 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 testing at issue was 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

The parent of an 11-year-old female enrollee has requested reimbursement for the FirstStep PLUS test provided on 11/23/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees severe attention deficit hyperactivity disorder (ADHD) and developmental delays. The physician reviewer found that CMA is recommended by the American College of Medical Genetics as a first-line test for patients with autism spectrum disorders. The yield of CMA in patients with autism spectrum disorders is estimated to be around 10%. While findings on CMA may not alter treatment of the features associated with autism spectrum disorders in all patients, CMA has become the standard of care in this clinical setting. Increasing numbers of patients with autism spectrum disorders have been found to have underlying copy number variations. As such, some copy number variations have also been associated with neuropsychological treatments or medications that have been shown to be more efficacious in this patient population. Additionally, copy number variations on CMA may inform about possible other complications and medical risks. All told, the FirstStep PLUS test provided on 11/23/16 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 testing at issue was 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 53-year-old male enrollee has requested reimbursement for the bronchial thermoplasty provided from 1/21/15 through 4/8/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees persistent asthma.   The physician reviewer found that three initial trials of bronchial thermoplasty have demonstrated improved symptom control after the procedure was completed. Cox and colleagues reported on the AIR trial, which examined 112 patients with moderate-to-severe asthma and demonstrated improved control over the course of the one year follow-up. Pavord and colleagues conducted the RISA study and examined the safety of thermoplasty. The authors found short-term worsening in symptoms, but evidence of improved long-term control of asthma. Castro and colleagues reported on the AIR2 trial, which compared thermoplasty with a sham procedure and followed the patients for 12 months as well. The patients in this study had milder asthma when compared with the AIR and RISA study, with far fewer on oral corticosteroids. Several years ago, two follow-up studies were performed establishing a long-term improvement in asthma control over five years after the bronchial thermoplasty was performed. A follow-up of 14 patients in the RISA trial by Pavord and colleagues found a decrease in emergency department visits and hospitalizations in each year after bronchial thermoplasty and no change in lung function. The follow-up of the AIR2 trial from Wechsler and colleagues showed sustained improvement in 162 of the 190 patients followed for the complete five years. As with the RISA data, this was manifested with fewer emergency department visits and hospital admissions with stable spirometry and a decrease in mean inhaled steroid use over that period of time. 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 2


A 53-year-old male enrollee has requested reimbursement for the bronchial thermoplasty provided from 1/21/15 through 4/8/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees persistent asthma.   The physician reviewer found the U.S. Food and Drug Administration (FDA) approved the procedure in 2010 as safe and effective for use in patients with poorly controlled asthma who fail to improve despite treatment with maximal medical therapy. Poorly controlled asthma affects a patients life in many ways. The fact that this patient requires multiple steroid bursts means that he is at increased risk for steroid side effects. Thus, due to the severity of the condition in this patient, that bronchial thermoplasty has the potential to lead to improved asthma control, decreased use of prednisone, perhaps the elimination of Xolair, and allergy shots. Since this procedure is only indicated for patients with severe asthma who are steroid dependent, as this patient, the bronchial thermoplasty services provided from 1/21/15 through 4/8/15 were 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 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.