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

Summary Reviewer 


A 39-year-old male enrollee has requested reimbursement for chiropractic treatment provided from 4/20/15 through 7/24/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition.  The physician reviewer found the review I am board certified in chiropractic orthopedics and I am actively practicing. I am an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. In addition, I hold a current certification by a recognized American medical specialty board in the area or areas appropriate to the treatment under review. I have no history of disciplinary action or sanctions against my license.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 56-year-old female enrollee has requested reimbursement for the three-dimensional (3D) mammogram (breast tomosynthesis) provided on 1/9/17. The Health Insurer has denied this request indicating that the service at issue is considered investigational for evaluation of the enrollees risk of breast cancer.  The physician reviewer found that despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantage it brings radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in overall diagnostic accuracy compared to two-dimensional (2D) imaging alone. Thus, the addition of tomosynthesis to the usual 2D protocol was likely of greater benefit to the patient than had her mammogram been done with 2D imaging alone. As such, the 3D mammogram (breast tomosynthesis) provided on 1/9/17 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 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 56-year-old female enrollee has requested reimbursement for the three-dimensional (3D) mammogram (breast tomosynthesis) provided on 1/9/17. The Health Insurer has denied this request indicating that the service at issue is considered investigational for evaluation of the enrollees risk of breast cancer.  The physician reviewer found there is a lack of peer-reviewed literature that supports the use of breast tomosynthesis compared to currently available techniques. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in the peer-reviewed literature as superior to currently available standard medical therapies. Accordingly, the 3D mammogram (breast tomosynthesis) provided on 1/9/17 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 service 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 56-year-old female enrollee has requested reimbursement for the three-dimensional (3D) mammogram (breast tomosynthesis) provided on 1/9/17. The Health Insurer has denied this request indicating that the service at issue is considered investigational for evaluation of the enrollees risk of breast cancer.  The physician reviewer found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. For the reasons provided, the 3D mammogram (breast tomosynthesis) provided on 1/9/17 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 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 50-year-old male enrollee has requested authorization and coverage for Prevymis (letermovir). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who is status post heart transplant. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient underwent a recent heart transplantation and has mild leukopenia. Although valganciclovir is known to be associated with leukopenia, other medications that the patient has been prescribed are also associated with leukopenia, such as Bactrim. The leukopenia present is not clearly due to valganciclovir. In addition, letermovir is approved for patients with hematopoietic stem cell transplant patients and has not been sufficiently evaluated in solid organ transplantation. Finally, bone marrow suppression also occurs using letermovir in the form of thrombocytopenia in up to 27% of patients. For these reasons, letermovir is not recommended prophylaxis for the management of cytomegalovirus in solid organ transplant recipients. Thus, Prevymis (letermovir) 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 59-year-old female enrollee has requested reimbursement for air and ground ambulance transportation services provided on 4/1/17. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees stage IV squamous cell carcinoma with significant functional decline. The physician reviewer found the air and ground ambulance transportation services provided on 4/1/17 were not medically necessary for treatment of the patients medical condition. There is a lack of support in the peer-reviewed medical literature for the services at issue in this clinical setting. In this case, hospice services were available for the patient in California. The request for air and ground transportation to New Jersey to be closer to family support was not medically necessary for treatment of the patients medical condition. 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 Upheld

Summary Reviewer 

The patient is a 57-year-old male who presented with a prostate-specific antigen (PSA) of 7.0. The patient has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that there is a lack of support for the requested services in this clinical setting. The patientas history of hemochromatosis is not sufficient to support the use of proton beam therapy for his prostate cancer. There is a lack of strong medical evidence to suggest that treatment with proton beam therapy is associated with a clinical benefit compared to standard treatment. Furthermore, proton beam therapy has not been validated in a comparative randomized study to standard treatment with photons. Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Vapiwala and colleagues performed a multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer and compared groups receiving hypofractionated radiation proton therapy and intensity modulated radiation therapy with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, it found no difference in disease control between the two modalities. The American Society of Radiation Oncology (ASTRO) stated, aProton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry.a ASTRO notes that the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and intensity modulated radiation therapy technique. Therefore, the requested proton beam therapy is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 58-year-old male enrollee has requested reimbursement for test for allergy or toxicity (immunoglobulin G (IgG) food sensitivity testing) performed on 3/14/18. 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 there is a lack of support for the services at issue in this clinical setting. If there is concern that the patient may have celiac disease, the proper test is a tissue transglutaminase antibody or endomysial antibody. The testing performed in this case was not indicated. Therefore, the test for allergy or toxicity (IgG food sensitivity testing) performed on 3/14/18 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 58-year-old male enrollee has requested reimbursement for test for allergy or toxicity (immunoglobulin G (IgG) food sensitivity testing) performed on 3/14/18. 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 the submitted documentation fails to demonstrate the superior efficacy of the services at issue. The current medical evidence does not support IgG food sensitivity testing in this clinical setting. The American College of Gastroenterology notes that immunoglobulin A (IgA) anti-tissue transglutaminase antibody is the preferred single test for detection of celiac disease in patients over the age of two years. In this patients case, celiac disease had already been endoscopically ruled out. Thus, IgG food sensitivity testing performed on 3/14/18 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 58-year-old male enrollee has requested reimbursement for test for allergy or toxicity (immunoglobulin G (IgG) food sensitivity testing) performed on 3/14/18. 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 there is a lack of high-quality clinical literature supporting the use of IgG food allergy testing for the investigation of gastrointestinal symptoms or irritable bowel syndrome. Notably, a number of national and international medical societies have expressed recommendations against the use of this testing and concern about its ongoing use for this indication. The American Academy of Allergy, Asthma and Immunology and American College of Allergy, Asthma and Immunology practice guidelines state that IgG and IgG subclass antibody tests for food allergy do not have clinical relevance, are not validated, lack sufficient quality control, and should not be performed. The American Academy of Allergy, Asthma and Immunology guideline for management of adverse reactions to foods states that measurement of specific IgG antibodies to foods is unproven as a diagnostic tool. Thus, IgG food sensitivity testing performed on 3/14/18 was not likely to be 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 Overturned

Summary Reviewer 
A 19-year-old female enrollee has requested authorization and coverage for jaw surgery. The Health Insurer has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees facial pain, mastication and nasal obstruction. The physician reviewer found that the submitted documentation demonstrates the medical necessity for the requested surgery. This patient has a maxillofacial skeletal deformity which has resulted in a functional deficit. The records noted that she has difficulty with mastication, speech and has associated facial pain. Her medical condition cannot be corrected with conservative non-surgical therapy alone. Instead, this patient requires orthognathic surgery intervention to correct her maxillofacial skeletal deformity. Performance of this surgery is likely to result in improved musculoskeletal, dento-osseous and soft tissue relationships which will result in improved mastication and swallowing for the patient. The surgery has also been shown to improve the associated temporomandibular joint and associated muscular disorders. As such, the requested jaw surgery is medically necessary for the treatment of this patients medical condition. Therefore, for the reasons stated above, the requested surgery 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

The patient is a 52-year-old female who presented with a well-defined nodular mass at the left acromioclavicular joint. The provider ordered magnetic resonance imaging (MRI) of the chest for evaluation. The patient had no history of trauma, fever or known malignancy. The patient has requested reimbursement for the MRI of the chest without contrast provided on 11/15/17. The Health Insurer has denied this request indicating that the diagnostic procedure was not medically necessary. The acromioclavicular joint is a common location for prominent physical findings and is usually due to a hypertrophic osteophyte or old healed fracture. Plain x-rays are typically considered sufficient to evaluate such findings if present. Moreover, if these findings were demonstrated on plain x-rays, this would have negated the need for MRI. Thus, without the initial radiograph as a guide for further imaging, the MRI of the chest without contrast provided on 11/15/17 was not medically necessary for evaluation of this patients medical condition.  Based on the foregoing, the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 35 hours per week of direct applied behavioral analysis (ABA) therapy and 3.5 hours per week of oversight provided from 7/1/16 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 autism.  The physician reviewer found that in this clinical setting, ABA therapy is medically necessary for treatment of the patients medical condition. The study by Mohammadzaheri and colleagues found that ABA is effective for treating disruptive behaviors in school aged children with autism.  Based on the documentation submitted for review, the patient requires a higher level of ABA therapy due to maladaptive behaviors including aggression, non-compliance, and a high level of self-injury. In addition, the patient has not mastered a majority of the goals included in the most recent progress report. In sum, the medical necessity for 35 hours per week of direct ABA therapy and 3.5 hours per week of oversight provided from 7/1/16 forward has been established as medically necessary for treatment of the patients medical condition. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 27-year-old male enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and associated inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease state that more evidence is needed before LINX can be recommended. Skubleny and colleagues concluded, aLong-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation.a Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. Sheu and Rattner concluded, aThe long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined.a The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment. LINX has significant potential adverse effects and can be associated with poor outcomes. Therefore, LINX Reflux Management System (code 43284) and associated inpatient bed day is not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 27-year-old male enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and associated inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that eligible patient for LINX Reflux Management System must demonstrate typical gastroesophageal reflux disease symptoms, an abnormal pH study, partial response to daily proton pump inhibitor (PPI) therapy, and absence of a large hiatal hernia (greater than 3 cm) or severe esophagitis per SAGES technology and value assessment. This patient has a normal BRAVO pH study done on 2/25/21 with normal acid exposure time of 4.1, and normal DeMeester score of 12.0. The study noted a normal symptom association probability of 0 with chest pain and 65 with throat pain. Thus, the patient did not fulfill the eligibility criteria of an abnormal pH study for LINX reflux management system. Therefore, LINX Reflux Management System (code 43284) and associated inpatient bed day is not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 27-year-old male enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and associated inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the current medical evidence has not established the superior efficacy of the requested services. Direct comparative studies between surgical interventions are needed to better assess the long-term safety and efficacy of this therapeutic intervention in patients. There is lack of randomized controlled trials comparing LINX with other surgical anti-reflux interventions, such as the Nissen fundoplication. Sheu and colleagues concluded that the long-term safety and efficacy of LINX remains to be determined by evaluating and investigating the safety, efficacy and durability of the intervention over time. Adverse events including erosion through the esophagus have been reported. Although the LINX device has been approved by the U.S. Food and Drug Administration, based on current evidence and medical literature, the technology has not met a consensus opinion or recommendation by medical societies and governing organizations. The requested service has not been rigorously tested in randomized controlled trials against other alternative therapies. Therefore, LINX Reflux Management System (code 43284) and associated inpatient bed day is not likely to be more beneficial than other available standard therapy.