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

Summary Reviewer 2


A 37-year-old female enrollee has requested authorization and coverage for bronchoscopic thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is investigational for treatment of the enrollees persistent asthma. The physician reviewer found that currently, the three trials of bronchoscopic thermoplasty have demonstrated improved symptom control after the procedure was completed. The AIR trial examined 112 subjects with moderated to severe asthma and demonstrated improved control over the course of the one year follow-up (Cox, et al). The RISA study examined the safety of thermoplasty and found short-term worsening in symptoms, but evidence of improved long-term control of asthma (Pavord, et al). The authors found that the thermoplasty group had fewer exacerbations and improved quality of life when compared to the sham group. The AIR2 trial had 30% of the enrolled patients in the thermoplasty group on other controlling agents and fewer patients on oral corticosteroids (Castro, et al). Several years ago, two follow-up studies were performed establishing a long term improvement in asthma control over five years after the bronchoscopic thermoplasty was performed. While this patient has severe asthma, likely allergic, her elevated IgE is not being addressed. Thus, prior to initiating bronchoscopic thermoplasty, the patient may respond to treatment with omalizumab. Accordingly, the requested bronchoscopic thermoplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 37-year-old female enrollee has requested authorization and coverage for bronchoscopic thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is investigational for treatment of the enrollees persistent asthma. The physician reviewer found that Bronchial thermoplasty is a procedure that uses a bronchoscope probe to provide thermal energy to the smooth muscle of the airway. The tissue is heated to 65 degrees Centigrade. There are three bronchoscopic procedures. The first procedure treats the right lower lobe, the second treats the left lower lobe, and the third bronchoscopic procedure is for both upper lobes. The procedures are scheduled three weeks apart. In the medical literature, the therapeutic effect of sham placebo bronchial thermoplasty was similar to bronchial thermoplasty. Castro and colleagues reported that providing thermal energy to the airway had no beneficial effect in their study of 288 patients. This patients provider states the patient has a progressive decrease in the quality of life but there is a lack of documentation that the use bronchial thermoplasty would improve the long-term functional outcome of the patients condition. For these reasons, the requested bronchoscopic thermoplasty is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, 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 reimbursement for blepharoplasty of the upper eyelid performed on 12/07/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the services at issue in this patients case. The blepharoplasty was not medically necessary based on the lack of appropriate visual field information. The visual fields provided were threshold tests in grayscale format. In order to determine superior eyelid scotoma, a suprathreshold static visual field is required. The provided fields did not demonstrate absolute superior scotomas, and printed results were in grayscale representation only, rather than the numerical visual field test results. This is not a reliable or appropriate visual field test to demonstrate superior visual field loss due to eyelid obstruction. Therefore, upper eyelid blepharoplasty performed on 12/07/18 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 54-year-old female enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. In addition, AASLD/IDSA the guidelines state that high priority for treatment owing to high risk for complications includes patients with fibrosis of Metavir F2. This patient has a Metavir of F2; hence, treatment is indicated. Therefore, Harvoni should be approved as medically necessary based on national guidelines. For the reasons provided, 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 Upheld

Summary Reviewer 


A 58-year-old female enrollee has requested reimbursement and prospective authorization and coverage for physical therapy services provided from 1/22/16 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 thoracic degenerative disc disease and facet dysfunction, lumbar foraminal and central stenosis. The physician reviewer found that although a multidisciplinary approach to spine pain including physical therapy may be beneficial, the goal of therapy is to transition to an independent home exercise program without continued dependence on supervised therapy. Based on the available records, the additional requested physical therapy is not supported as a specific and effective treatment for this patients medical condition. The documentation does not indicate that prior extensive physical therapy has resulted in significant objective increase in overall function. Moreover, the services provided from 1/22/16 forward do not need to be only under the supervision of a therapist. The patient has had extensive prior physical therapy and should be well versed in a home exercise program. The patients expected rehabilitation potential is not significant in relation to the extent and duration of the physical therapy services. The specialized skill of a qualified therapist is not required to establish, design and/or deliver a maintenance program to maintain the patients current condition or to prevent or slow further deterioration. All told, the physical therapy services provided from 1/22/16 forward were not and are not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were not and are 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 72-year-old male enrollee has requested reimbursement for brachytherapy performed on 7/5/17 through 7/31/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees basal and squamous cell cancer. The physician reviewer found that there is support in the medical literature for the services at issue. Radiation therapy is an option for the initial management of small, well defined, primary cutaneous squamous cell carcinomas. It is primarily reserved for older patients and patients who are not surgical candidates due long term side effects. According to the documentation provided, this patient meets the standard criteria. Brachytherapy is the standard of care for treating this patients primary cutaneous squamous cell carcinomas. In sum, the brachytherapy performed on 7/5/17 through 7/31/17 was medically necessary for the treatment of this patients medical condition. Therefore, for the reasons stated above, 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 female enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) and nerve conduction velocity (NCV) studies provided on 9/22/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Hashimotos thyroiditis.   The physician reviewer found that the Thyroid Trio testing comprises three different tests that are not routinely recommended by providers caring for patients with thyroid problems. There is a lack of medical literature supporting the utility of the MTHFR and NCV studies in this clinical setting. Further, the American Thyroid Association Task Force on Thyroid Hormone Replacement does not include the testing used in this case for evaluation of this patients medical condition. All told, the MTHFR and NCV studies performed on 9/22/15 was not 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 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 Overturned

Summary Reviewer 2


A 60-year-old female enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) and nerve conduction velocity (NCV) studies provided on 9/22/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Hashimotos thyroiditis.   The physician reviewer found that Crone and Krarup noted diagnostic considerations for use of NCV are based on a flow chart classifying neuropathies into eight categories based on mode of onset, distribution, and electrophysiological findings, and the electrophysiological characteristics in each type of neuropathy are discussed. NCV is useful for evaluation of neurologic deficits but is not recommended in the absence of neurologic symptoms or physical findings. The medical records do not indicate physical exam findings of focal neurologic deficit or symptoms in support of NCV testing. In addition, NCV testing is not supported for evaluation of Hashimotos thyroiditis. As there are no neurologic symptoms or findings reported, NCV studies were not appropriate for evaluation of this patients medical condition. There is one publication in regard to MTHFR use for association with Hashimotos disease, but there is a lack of support for clinical application for individual clinical determination. Arakawa and colleagues found that some data suggests that a certain genotype correlates with DNA hypomethylation and with the intractability of goiter, and another genotype may correlate with the severity of Hashimotos disease. However, the authors noted that additional studies are needed to determine clinical correlation. Consistent with these findings, the MTHFR and NCV studies provided on 9/22/15 were not 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 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 Overturned

Summary Reviewer 3


A 60-year-old female enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) and nerve conduction velocity (NCV) studies provided on 9/22/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Hashimotos thyroiditis.   The physician reviewer found that based on current medical guidelines, the MTHFR and NCV testing performed on 9/22/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Neither of these tests are integral to the management and treatment of the patients hypothyroidism. While patients with hypothyroidism may experience neuropathy and muscle complaints, a NCV test is generally not indicated to diagnose or treat this condition. MTHFR testing has no role in the treatment of patients with hypothyroidism and Hashimotos thyroiditis. Recent data indicates that there is a lack of evidence for this type of testing in this clinical setting. Based upon the information set forth above, the testing at issue was 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 37-year-old female enrollee has requested authorization and coverage for escitalopram three tablets 20 mg daily. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the United States Food and Drug Administration (FDA) provides medication dose recommendations based on scientific data. The interpretation and application of these recommendations falls upon providers working directly with the patient population. This process allows for consideration of additional factors, such as provider experience, emerging treatment trends and clinical issues unique to individual cases, in the delivery of evidence-based, patient-centric care. As such, systematic medication titration is a core element of the art of medical practice and a key component to patient-centered care. Escitalopram is a potent and highly selective serotonin reuptake inhibitor (SSRI) that acts by binding directly to the serotonin transporter. Like other SSRI medications, escitalopram is a trusted intervention in the treatment armamentarium for those suffering from OCD. Providers have long recognized that the treatment of OCD often requires supra-therapeutic SSRI dosing. This practice is supported by the American Psychiatric Association (APA) clinical practice guideline for OCD which supports the occasionally prescribed maximum dose of escitalopram is 60 mg per day. Considering the medical records, community standards, endorsement from the APA and the peer-reviewed literature base, escitalopram 60 mg daily represents a safe, appropriate treatment consistent with good medical practice. The requested medication is reasonably expected to improve the patients condition and prevent a more serious episode of illness.  As such, the requested escitalopram three tablets 20 mg daily are medically necessary for treatment of the patients behavioral health condition. Therefore, 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 Upheld

Summary Reviewer 


A 28-year-old male enrollee has requested reimbursement for residential rehabilitation level of care services provided from 8/4/16 through 8/19/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse. The physician reviewer found that this patients records did not include any psychiatric or medical admitting evaluations. In addition, the patient did not present with any significant post-acute withdrawal symptoms. The patient was not a danger to himself or to others. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant RTC level of care. He was medically and psychiatrically stable. He was motivated, insightful, and appeared to be working the program. He reported having had a multitude of prior treatments, with the ability to maintain abstinence for a prolonged period of time. Relapse risk is inherent among this population but is not alone an adequate reason to keep a patient at a higher level of care in the absence of unstable psychiatric illness or the potential for harm to self or others. Given the recidivistic nature of his illness with multiple relapses and subsequent treatments, he had the groundwork of relapse prevention education. His difficulties with abuse and relapse were chronic in nature and did not require 24-hour monitoring at the RTC level of care in the absence of unstable medical or psychiatric conditions. He could have safely been treated in a less restrictive level of care. Thus, the RTC rehabilitation level of care services provided from 8/4/16 through 8/19/16 were not medically necessary for treatment of this patients polysubstance abuse. Based on the foregoing discussion, 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 22-year-old male who presented at age 19 with chest pain. The patient has requested reimbursement for the PET scan performed on 4/21/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that sarcomas of the heart are exceedingly rare tumors. Most cardiac tumors are benign, and of those that are malignant, the most common are angiomyosarcomas and rhabdomyosarcomas. Of the very rare cardiac sarcomas, synovial sarcomas account for only a tiny percentage. Hence, there is a lack of literature that has evaluated the efficacy of follow-up PET/CT scanning. In this patientas case, considering the high-grade nature of the tumor, as well as the size and presence of necrosis when the tumor was first discovered, there is a high likelihood of recurrence. Information was not submitted concerning whether the initial tumor resection had clean margins. The patient has continued on chemotherapy in spite of no evidence of metastasis or residual tumor. It is unclear what markers are being followed, other than a prophylactic suspicion of recurrence. Sarcomas most commonly recur locally, although they can metastasize (most commonly) to the lungs. One prognostic sign of a likely spread of tumor is tumor necrosis, as was noted in this patient. In order to effectively screen this high risk (and young) patient with CT scanning, one would have to do multiple scans to cover the entire body. Considering the lack of pertinent research and considering the highly aggressive tumor and the fact that the patient continues on chemotherapy, it is medically appropriate to continue the current regimen with regular MRI studies and PET/CT scans. This is especially valuable considering that the patient has a good set of baseline studies. There is sufficient support for the services at issue in this clinical setting. Therefore, the PET scan performed on 4/21/20 was 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 reimbursement for breast tomosynthesis performed on 9/26/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her examination been done with two-dimensional imaging alone. Based upon the information set forth above, the service 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


A 59-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 9/26/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found there is sufficient support for the service at issue in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  In sum, breast tomosynthesis performed on 9/26/16 was likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the service 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.