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

Summary Reviewer 


The parent of a 20-month-old female enrollee has requested authorization and coverage for Synagis.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation supports the requested services in this clinical setting.  Fauroux and colleagues noted increased respiratory morbidity in infant born less than 33 weeks gestation even in the absence of bronchopulmonary dysplasia.  This patient was born prematurely at 33 weeks twin gestation with a medical history significant for chronic lung disease, tracheoesophageal fistula complicated by esophageal tear and difficulty managing secretions.  The records document severe gastroesophageal reflux disease and feeding intolerance requiring gastrostomy tube feedings.  Because of her prematurity complicated by chronic lung disease, gastroesophageal reflux disease, and tracheoesophageal fistula, she is at risk for severe respiratory syncytial virus disease.  Therefore, Synagis is medically indicated for the treatment of this patient.  Therefore, the requested services are 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 48-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 1/26/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the current medical evidence supports the services at issue in this patients case.  According to 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 1/26/16 was likely to have been of greater benefit than other methods of evaluation.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 48-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 1/26/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  However, in this patients case, there were no problems to be resolved.  The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications.  In this clinical setting, a routine mammogram would have been sufficient.  Breast tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to multiple prior mammograms.  Therefore, breast tomosynthesis performed on 1/26/16 was not likely to have been of greater benefit than other modalities for 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 Overturned

Summary Reviewer 3


A 48-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 1/26/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often enables the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks, increase in accuracy and increase in detection of small cancers. For this reason, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the examination been done using two-dimensional imaging alone.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 48-year-old female enrollee has requested reimbursement for electroretinography performed on 8/17/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there is a lack of support for the use of multifocal electroretinography to diagnose this patients condition. In this case, the patient has a history of diabetes and retinopathy with abnormal fundus appearance consistent with non-proliferative diabetic retinopathy. Electroretinography measures electrical responses of the retina from light stimulus. Different types of retinal cell and their functional state can be measured. It is most useful for the diagnosis of hereditary retinal and choroidal diseases and dystrophies. Studies show that it is useful in diagnosing disease that does not have significant visible markers, as well as diseases that are uncommon and have similar clinical appearances, but varying courses. Electroretinography can assess the functional status of the retina in different stages of retinopathy. There is evidence to suggest that it can detect damage from retinopathy before there are visible changes on examination. However, the utility of this in terms of diagnosis and treatment of diabetic retinopathy has yet to be established. Electroretinography testing is not the standard of care in this situation. The standard of care for the diagnosis of diabetic retinopathy is dilated fungus examination using slit-lamp biomicroscopy and indirect ophthalmoscopy. Therefore, electroretinography performed on 8/17/18 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 48-year-old female enrollee has requested reimbursement for electroretinography performed on 8/17/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the medical records indicate that the patient has a history of diabetes and diabetic retinopathy. The biggest ophthalmic risk from diabetes is diabetic retinopathy, which can also lead to diabetic macular edema. If not successfully treated, these conditions can lead to permanent loss of vision.  Most ophthalmologists in the United States diagnose diabetic retinopathy and diabetic macular edema with a combination of physical examination of the retina through dilated pupils with indirect ophthalmoscopy and optical coherence tomography.  Fundus photographs may be used to document the extent or severity of diabetic retinopathy for progression. Optical coherence tomography angiography and fluorescein angiography are used to document poor vascular perfusion or leakage in diabetic retinopathy/diabetic macular edema. Electroretinography uses a flash of light to generate an electromagnetic signal within the retina, which is then captured by an electrode on the surface of the eye. Jansson and colleagues noted photopic full-field electroretinography and spectral-domain optical coherence tomography derived retinal thickness parameters have limited clinical value in the staging of diabetic retinopathy. There is a lack of evidence indicating that electroretinography is a functionally useful tool in diagnosing diabetic retinopathy at this time. In sum, electroretinography performed on 8/17/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 48-year-old female enrollee has requested reimbursement for electroretinography performed on 8/17/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that diabetic retinopathy is a clinical diagnosis that is based on findings of the anterior segment and dilated fundoscopic examination. Signs of non-proliferative diabetic retinopathy include retinal dot blot hemorrhages, microaneurysms and macular edema. There are ancillary tests that aid in the diagnosis, including fluorescein angiography and optical coherence tomography.  Electroretinography is a diagnostic test used to detect and quantify electrical activity given off by retinal cells to a light stimulus.  It is often used in diagnosis of retinal dystrophies, such as retinitis pigmentosa, Stargardts disease, and acquired conditions, such as retinal toxicity from long-term Plaquenil use.  Electroretinography is not commonly utilized in the diagnosis of diabetic retinopathy.  It can give additional information regarding overall health of the various components of the retina, but is not used to diagnose or guide management. The medical evidence does not support the services at issue in this clinical setting. Thus, electroretinography performed on 8/17/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 52-year-old female with a history of chronic low back pain status post Coflex spacer at L4-5.  The patient has requested reimbursement for total disc arthroplasty performed on 7/31/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. As noted by Fornica and colleagues, the two main surgical treatments for lumbar degenerative disc disease are lumbar fusion and total disc arthroplasty. Lumbar fusion relieves pain by fusing vertebrae together, but may result in incomplete pain relief, reduced range of motion, and increased risk of adjacent segment degeneration with recurrent pain. The lumbar total disc replacement avoids these complications by replacing the degenerated disc with a moveable prosthesis, thus relieving pain, preserving motion, and avoiding adjacent segment degeneration. The implants and the procedure have been refined over the years, and good results have been documented. Therefore, the total disc arthroplasty performed on 7/31/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 26-year-old female enrollee has requested reimbursement for residential treatment center (RTC) services provided from 9/7/18 through 9/18/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found that the American Psychiatric Association (APA) treatment guidelines state that RTC is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. During the period under review, this patient required safe and stable living environment in order to develop recovery skills. Applying the American Society of Addiction Medicine (ASAM) guidelines, this patient met the criteria for Level III treatment, consistent with RTC level of care. The standard practice for RTC level of care services is a 30-day program, which was appropriate for this patient given her difficulty with family relationships and significant trauma history placing her at elevated risk for relapse. RTC level of care services was in accordance with generally accepted standards of medical practice and clinically appropriate for the patients illness. Thus, the RTC services provided from 9/7/18 through 9/18/18 were medically necessary for treatment of this patients behavioral health issues. Based on this discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer

The patient is a 57-year-old female who presented to urgent care on 7/12/18 for evaluation of left medial knee pain and swelling. Radiographs were obtained, reportedly demonstrating mild osteoarthritis, although no formal interpretation is available. The patient had a follow-up office visit on 7/31/18. On this date, the provider recommended physical therapy and the use of a knee brace. On 9/20/18, the patient reported mild improvement in symptoms after utilizing a knee brace, with little benefit from physical therapy. The patient has requested coverage for magnetic resonance imaging (MRI) of the left knee. The Health Insurer has denied this request indicating that the requested services are not medically necessary for the evaluation of this patient. The submitted documentation fails to demonstrate the medical necessity of the requested services. The best initial imaging examination for the evaluation of chronic knee pain in an adult is radiographs. In the setting of osteoarthritis diagnosed by initial radiographs, MRI may be indicated in follow-up if the patients symptoms are not explained by the radiographic findings. According to the American College of Radiology appropriateness criteria for the evaluation of chronic knee pain in an adult with initial radiographs demonstrating degenerative changes, MRI may be appropriate as the next imaging examination. In this patients case, radiographs were reportedly obtained at an urgent care visit, although there was no formal radiological interpretation. Interpretation, presumably by the urgent care provider, reported mild osteoarthritis. In this patients case, a formal interpretation of the patients radiographs is necessary. The preliminary report issued by an urgent care physician may differ from an official report from a radiologist, possibly changing management. Thus, the requested MRI of the left knee is not medically necessary for the evaluation of this patient. Therefore, the requested services are not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 19-year-old female enrollee has requested reimbursement for residential treatment center services provided from 4/1/15 through 6/30/15 and 8/1/15 through 8/13/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.  The physician reviewer found that the RTC services provided from 4/1/15 through 6/30/15 and 8/1/15 through 8/13/15 were not medically necessary for treatment of the patients medical condition. To objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. As of 4/1/15, the patients risk of harm score is two (2), mild risk of harm. The patient has a history of self-injurious behavior. There was no documentation of prior suicide attempts. However, on 4/1/15, the patient did not have any suicidal ideation and had not had any recent self-injurious reports. The patients functional status score is two (2), mild functional impairment. By 4/1/15, the patient had made much improvement. She was focusing on her schoolwork. Her sleep, appetite, and mood were normal. There were no changes made to her Wellbutrin dosage. The patients co-morbidity score is three (3), significant co-morbidity. The patient has a co-morbidity of cognitive disorder NOS and depressive disorder NOS. The patient also has damaged lungs and vocal cords. However, from the documentation, it did not appear that the patient required 24 hour assistance. The patients recovery environment stress score was three (3), moderately stressful environment. The patients biological father and step-mother are going through a divorce. The patient is very close to her step-mother. The patients environmental support score is two (2), supportive environment. The patients father and stepmother are supportive of the patient. The patients resiliency score is two (2), significant response to treatment. By 4/1/15, documentation attests that the patient has made significant response to treatment. The patients acceptance and engagement, score (1), optimal. The patient has positive relationships with providers. She actively participates in treatment planning and cooperates with treatment. Based on these criteria, the patient has a composite score of 15, which would meet criteria for outpatient treatment. The patient continued to need treatment for her cognitive disorder NOS, depressive disorder NOS, and parent-child relational problem, but this could have been safely and adequately provided in a less restrictive environment. For the reasons provided, 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 parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for applied behavioral analysis (ABA) therapy provided from 2/23/17 through 8/23/17. 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 spectrum disorder. The physician reviewer found that Brosnan and Healy indicate that ABA therapy is an effective treatment to reduce aggressive behavior in individuals with autism spectrum disorder. Hanley and colleagues also report that ABA is highly effective in reducing problematic behaviors. According to the documentation submitted for review, the patient engages behaviors that pose a danger to himself and others, particularly his aggressive and injurious behavior, and his behavior when traveling in a car. There are several areas in which the patient has made no progress during the last authorization period, including the areas of social, play and cognition, adaptive/motor skills, and executive function. ABA therapy at the providers recommended frequency are medically necessary to address the patients behavioral challenges is clinically indicated for this patient. Therefore, the request for 20 hours per week of direct ABA therapy, eight hours per month of supervision, two hours per month for treatment planning and two hours per month for parent training provided from 2/23/17 through 8/23/17 were and are 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 49-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The records document chronic left knee pain due to a history of chondral defects in the patellofemoral joint. Focal chondral defects are common in the patellofemoral joint, are difficult to treat and can significantly impair the quality of life of the affected individuals. The autologous chondrocytes implantation technique has been used and perfected over 20 years with the current U.S. Food and Drug Administration (FDA) approved third generation technique called matrix-induced autologous chondrocyte implantation. 
The study by Niemeyer and colleagues included a total of 6,425 patients who fulfilled the inclusion criteria, 6,273 who were treated with microfracture and 152 who were treated with matrix-induced autologous chondrocyte implantation. In the two years after treatment, 1,271 patients in the microfracture group needed a reoperation, compared with 19 in the matrix-induced autologous chondrocyte implantation group. According to Welch and colleagues, recent evidence suggests that autologous chondrocyte implantation should be considered as a first-line treatment option in select patients. Autologous chondrocyte implantation is an effective means for cartilage restoration. Therefore, the requested autologous chondrocyte implantation is medically necessary for the treatment of this patient.