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

Summary Reviewer 


A 44-year-old male enrollee has requested reimbursement for the substance abuse partial hospitalization program (PHP) services provided from 11/10/15 through 12/3/15. 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 the records provided for review indicate that this patient did not experience any withdrawals and did not endorse cravings during the period under dispute. He was not a danger to himself or others. He was medically stable. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant treatment at the PHP level of care. His mood was stable and he showed no psychiatric symptoms that required monitoring multiple days per week for multiple hours per day. He was engaged in groups and individual treatment, but did not go to outside meetings and did not have outside support systems in place. He had a history of multiple treatments since 2014, and almost continuous treatment since September 2015. During this course of treatment, the patient did not appear to have progressed significantly enough to warrant PHP level of care. The trauma and resolution work needed could have been safely and adequately managed in the outpatient setting. Further relapse prevention could have taken place on an outpatient basis via 12-step meetings, obtaining of a sponsor, and counseling. He did not require PHP for his psychiatric medication management, as this too could have been accomplished on an outpatient basis. All told, the PHP services provided from 11/10/15 through 12/3/15 were not medically necessary for treatment of this patients behavioral health issues.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 47-year-old male enrollee has requested authorization and coverage for ultralightweight wheelchair. The Health Insurer has denied this request and reported that the requested equipment is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the available records indicate that the patient has been diagnosed with hypokalemic periodic paralysis.  Periodic paralyses are rare neuromuscular disorders that typically present clinically with intermittent focal or generalized muscle weakness, often precipitated by triggers, including alterations in serum potassium levels. The records otherwise indicate that extensive diagnostic testing and follow up at a neurology clinic has not revealed evidence of myotonic disease, motor neuron disease, myopathy, Kennedys disease, mononeuropathy, myopathy, myotonic dystrophy or other condition. The wheelchair has been recommended for the patients functional issues. The physical examinations and functional evaluations that are documented in the available records, however, have not shown functional impairments that would preclude the patient from accomplishing his mobility-related activities of daily living. Notably, the most recently documented gait examination in the available records showed a narrow based gait with a normal arm swing and normal stride. Functionally, while the patient is experiencing fatigue and near falls, there are no objective indications that he is unable to accomplish his mobility-related activities of daily living without the proposed ultralight manual wheelchair. It is reported, moreover, that he may be undergoing surgeries for his shoulders in the near future, which may potentially preclude him for operating the proposed wheelchair altogether for an indefinite period of time. The submitted records fail to demonstrate the medical necessity of the requested device. Therefore, the requested ultralightweight wheelchair is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 10-year-old male enrollee has requested reimbursement and prospective authorization and coverage for intensive behavioral therapies (33 hours per week of H2019) provided from 1/03/19 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees autism. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The VB-MAPP report indicated that the patient was performing at the approximate level of an 18 to 30 month old. The records documented aggressive behavior, elopement, and pica/mouthing. While aggression is relatively low, elopement and pica/mouthing occurred more frequently and can be dangerous. It is important that the patient continue to receive ABA treatment to decrease the frequency of these behaviors and learn appropriate alternative/replacement behaviors. Further, the listed goals throughout the authorization plan highlight the need for a more intense level of service. In this patients case, the results of the VB-MAPP assessment, frequency of problem behavior, and barriers assessment supported 33 hours of CPT code H2019 per week. ABA therapy is the most evidence-based treatment for individuals on the autism spectrum. The medical evidence supports the services at issue in this clinical setting. Therefore, intensive behavioral therapies (33 hours per week of H2019) provided from 1/03/19 forward were and are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 32-year-old female enrollee has requested authorization and coverage for Enbrel. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees ankylosing spondylitis. The physician reviewer found that Enbrel is an anti-tumor necrosis factor (TNF) medication used to treat inflammatory arthritis. The available medical records do not contain documentation of active arthritis. There is a lack of evidence of synovitis on physical examination and there is no record of symptomatology consistent with inflammatory lower back pain or inflammatory peripheral joint disease. There is no radiographic documentation of inflammatory arthritis of the spine or peripheral joints. On the basis of this lack of documentation, the request for Enbrel 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 medication is 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 32-year-old female enrollee has requested authorization and coverage for Enbrel. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees ankylosing spondylitis. The physician reviewer found that Enbrel is appropriate for this patients diagnosis of ankylosing spondylitis. However, if the patient does have systematic lupus erythematosus, than it is not suggested to use Enbrel or other anti-tumor necrosis factor (TNF) agents as these drugs can trigger lupus. Given the presentation in the records, the patient does not have systematic lupus erythematosus, rather she carries a low titer double stranded deoxyribonucleic acid (dsdna) antibody which is being monitored. Thus, the requested Enbrel is 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 medication is 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 32-year-old female enrollee has requested authorization and coverage for Enbrel. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees ankylosing spondylitis. The physician reviewer found that in this case, the patient has ankylosing spondylitis with active peripheral arthritis. She has failed methotrexate, Plaquenil and NSAIDs. In the medical literature, Callhoff and colleagues reported their meta-analysis demonstrates efficacy of tumour necrosis factor (TNF) alpha blockers versus placebo for the treatment of ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis. In this case, the patient has failed standard therapy and continues to have active disease. As such, the request for Enbrel is 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 medication is 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 1


A 55-year-old female enrollee has requested authorization and coverage for botulinum toxin type A (Botox) treatment and ongoing treatment. 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 that review of the submitted documentation and relevant literature supports the use of Botox injections in this clinical setting. According to the literature review by Szok and colleagues Recent clinical studies revealed that onabotulinumtoxinA was an efficacious and safe treatment for chronic migraine. The documentation submitted for review documents the patient is diagnosed with chronic migraine headaches with at least 14 headache days per month. This patient has tried other prophylactic measures without success. In addition, Botox is U.S. Food and Drug Administration (FDA) approved for the treatment of chronic migraine. For the reasons provided, the request for Botox injections and ongoing treatment are 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 services are 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 55-year-old female enrollee has requested authorization and coverage for botulinum toxin type A (Botox) treatment and ongoing treatment. 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 that ongoing Botox treatment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient presents with a long history of migraine headaches dating to childhood. The records indicate that before starting Botox she had a baseline headache frequency of 16 to 24 per month, which is consistent with the diagnosis of chronic migraine. In addition, the patient has had a marked improvement documented with Botox treatments for more than 10 years. In sum, Botox treatment for chronic migraine is indicated for this patient and ongoing treatments are 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 services are 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 55-year-old female enrollee has requested authorization and coverage for botulinum toxin type A (Botox) treatment and ongoing treatment. 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 that although Botox is not indicated for every patient with a migraine disorder, it can provide relief in a subset of patients and is U.S. Food and Drug Administration (FDA) approved for this indication. In this particular case, the patient failed multiple first-line therapies and had a documented response to Botox. While not treated with Botox she experienced a significant worsening of her headache frequency. For these reasons, the requested ongoing treatment with Botox is 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 services are 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 1

The patient is a 39-year-old female whose history is significant for having a child with Coffin-Siris syndrome with a mutation noted in SMARCA4. She has requested reimbursement for SMARCA4 gene mutation and chromosome testing performed on 8/14/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  Given the patients age and prior affected child, testing for both fetal aneuploidy and the known gene mutation were medically appropriate. While the initial plan was to perform testing with chorionic villus sampling, the procedure did not yield adequate villi for testing. The patient then underwent cell-free fetal DNA testing for fetal aneuploidy.  This was medically indicated since the American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine recommend cell-free DNA testing as a screening option for women at increased risk of fetal aneuploidy. Due to the patients age, the aneuploidy risk for this patient warranted cell-free DNA testing for aneuploidy.  Since this test would not address the recurrence risk of the SMARCA4 mutation in the current pregnancy, the patient then underwent amniocentesis. While the testing for the SMARCA4 gene mutation in the amniotic fluid was medically indicated, there was no medical indication to perform a karyotype on the amniotic fluid, as the cell-free fetal DNA was normal. In sum, the testing for SMARCA4 gene mutation was likely to have been more effective than other methods of evaluating this patient, but the superior efficacy of the chromosome testing on 8/14/17 has not been established. Based upon the information set forth above, a portion of the services 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 partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

The patient is a 39-year-old female with a child diagnosed with Coffin-Siris syndrome. She underwent testing during a subsequent pregnancy. She has requested reimbursement for SMARCA4 gene mutation and chromosome testing performed on 8/14/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  There is sufficient support for the services at issue in this clinical setting. When counseling patients with the sole risk factor of advanced maternal age, in the first trimester of pregnancy, several genetic testing options are discussed. These options include no testing or a first trimester screen, usually called the QUAD screen, which consists of serum markers typically done between 15 and 19 weeks. Both tests would also be appropriate to discuss with women under the age of 35. Additionally, for women over the age of 35, since their individual risk of genetic abnormalities increases, additional screening options and invasive testing such as amniocentesis or chorionic villus sampling should be offered along with genetic counseling. This patient desired screening for her risk of trisomy, given her advanced maternal age. She also wished to screen for the SMARCA4 gene mutation given a history of a child with a syndrome related to this gene mutation. Given this patients age, previous pregnancy/birth history, and increased risk above the population risk for a specific gene mutation that can have significant and grave consequences, the services at issue were medically appropriate. In sum, SMARCA4 gene mutation and chromosome testing performed on 8/14/17 were likely to have been more effective than other methods of evaluating this patient. 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 3

The patient is a 39-year-old female who underwent genetic testing during pregnancy.  Specifically, she underwent testing for the SMARCA4 gene mutation. The patient had a prior affected child with the SMARCA4 gene mutation leading to the child having Coffin-Siris syndrome. She has requested reimbursement for SMARCA4 gene mutation and chromosome testing performed on 8/14/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  There is sufficient support for the services at issue in this clinical setting. Per the records, there is a higher chance than the general population that the fetus may have the gene mutation SMARCA4 leading to Coffin-Siris syndrome.  Since this patient already had a severely affected offspring, the information from this testing was important in making important medical decisions regarding the pregnancy. Thus, SMARCA4 gene mutation and chromosome testing performed on 8/14/17 were likely to be of greater benefit than other modalities for evaluating this patient. 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 male enrollee has requested reimbursement for polymerase chain reaction (PCR) testing performed on 7/15/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that in this case, the patient presents with fatigue of intermittent duration over several years. The exam findings are unremarkable. The laboratory studies are normal or negative. The records submitted for review do not demonstrate a diagnosis of Lyme disease. He has had negative IgG and IgM serologic assays. Acute Lyme disease may have IgM positivity and late stage Lyme disease has IgG positivity. The medical records submitted fail to provide a clinical indication for PCR testing in the presence of a negative serology. Moreover, there is a lack of evidence demonstrating the presence of either early or late stage Lyme disease. Accordingly, the PCR testing performed on 7/15/15 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 Upheld

Summary Reviewer 2


A 48-year-old male enrollee has requested reimbursement for polymerase chain reaction (PCR) testing performed on 7/15/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the PCR testing performed on 7/15/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the patient presented with non-specific complaints and few risk factors for Lyme disease. PCR testing is not a recommended testing method based on Centers for Disease Control and Prevention (CDC) guidelines. The recommendation for treatment and diagnosis of Lyme include Elisa and Western blot testing (Wormser, et al). For these reasons, the testing at issue was not indicated for evaluation of the patients medical condition.  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 Upheld

Summary Reviewer 3


A 48-year-old male enrollee has requested reimbursement for polymerase chain reaction (PCR) testing performed on 7/15/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient had negative serological testing. PCR testing is not the standard of care in making a diagnosis of Lyme disease. Testing can be effectively used on synovial fluid in cases of suspected Lyme arthritis and on cerebrospinal fluid (CSF) when there is suspicion of neurologic Lyme disease. In sum, PCR testing is not indicated unless there is clear serological evidence of Borrelia infection, which was not present in this case. Therefore, the PCR testing performed on 7/15/15 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of an eight-year-old female enrollee has requested authorization and coverage for Nutropin AQ Nuspin. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees idiopathic short stature. The physician reviewer found that in 2003, the U.S. Food and Drug Administration (FDA) approved the use of growth hormone therapy for idiopathic short stature or non-growth hormone-deficient short stature defined as height standard deviation less than or equal to -2.25 or less than or equal to 1.2nd percentile or age and gender. This patient meets the criteria for idiopathic short stature and has shown good response to growth hormone treatment with adequate monitoring and minimal side effects. She also had a poor pre-treatment growth velocity and poor final height prediction, which is greater than two standard deviations below the mid-parental height. Continued growth hormone therapy is medically appropriate in this clinical setting. Thus, Nutropin AQ Nuspin is medically necessary for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.