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

Summary Reviewer 


A 63-year-old male 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 chronic hepatitis C virus genotype 1a.  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. Due to thrombocytopenia, this patients provider noted that he is not a candidate for treatment with interferon. All told, the requested treatment with Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection. In sum, the requested medication is 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 37-year-old female enrollee has requested reimbursement for the Afirma thyroid fine needle aspiration (FNA) analysis provided on 1/15/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees pituitary tumor and elevated prolactin.  The physician reviewer found that 
the National Comprehensive Cancer Network (NCCN) indicated that genetic profiling for atypia of unknown significance is a category 2b recommendation. In the medical literature, Duick and colleagues reported that obtaining a gene expression classifier in patients with cytologically indeterminate nodules is associated with a striking reduction in the rate of diagnostic thyroidectomy. Thus, in conjunction with peer-reviewed literature, the Afirma thyroid analysis performed on 1/15/15 was likely to have been more beneficial for thorough evaluation of this patients condition than any available testing. 
Based upon the information set forth above, I have determined 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 37-year-old female enrollee has requested reimbursement for the Afirma thyroid fine needle aspiration (FNA) analysis provided on 1/15/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees pituitary tumor and elevated prolactin.  The physician reviewer found that while a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate (Alexander, et al). Until recently, the only way to establish whether the nodule was consistent with cancer was via surgical excision (Miller, et al). The Afirma thyroid FNA analysis from Veracyte utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because the Afirma thyroid test is very sensitive and has a high negative predictive value, a negative result is suggestive of a benign nodule (Duick, et al). Given this support, the Afirma thyroid FNA analysis provided on 1/15/15 was likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined 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

A 37-year-old female enrollee has requested reimbursement for the Afirma thyroid fine needle aspiration (FNA) analysis provided on 1/15/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees pituitary tumor and elevated prolactin.  The physician reviewer found that Thyroid nodules are commonly managed by diagnostic FNA to evaluate the cytopathology. In this case, the finding by this standard technique was atypia of undetermined significance (Baloch, et al). This diagnostic category creates a dilemma with regards to recommended surgery. In this case, the patient was facing total thyroidectomy if malignancy was present and but only subtotal thyroidectomy if the lesion turned out to be benign. Hence, the sample was submitted to Veracyte for gene expression analysis. The Afirma gene expression test conducted by Veracyte has demonstrated a very high negative predictive value for malignancy (Alexander, et al; Chudova, et al). All told, the current peer-reviewed medical literature supports the diagnostic utility of the Afirma thyroid FNA analysis provided on 1/15/15 as likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined 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 58-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Plan has denied this request indicating that the requested procedure is considered investigational for the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found the U.S. Food and Drug Administration (FDA) has approved the LINX Reflux Management System for the treatment of lower esophageal sphincter augmentation. The device is a ring made up of a series of magnets that have sufficient attraction to increase the lower esophageal sphincter (LES) closure pressure, but allow for food passage with swallowing. Reynolds and colleagues performed a study comparing the LINX procedure with laparoscopic fundoplication was performed which used propensity matching to compare groups. The authors found that GERD patients had similar control of reflux symptoms after both LINX and fundoplication. The inabilities to belch and vomit were significantly fewer with LINX, along with a significantly lower incidence of severe gas-bloat symptoms. In addition, a five-year cohort data was recently published establishing the durability of LINX. In a group of 85 patients augmentation of the lower esophageal sphincter with a magnetic device provided significant and sustained control of reflux with minimal side effects or complications. Given the support cited above, the LINX procedure 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 procedure 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 Upheld

Summary Reviewer 2


A 58-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Plan has denied this request indicating that the requested procedure is considered investigational for the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found the appropriate patient selection is crucial before anti-reflux procedures. In prelude to surgical intervention for GERD, it is critical to document the presence of abnormal distal esophageal acid exposure, especially when anti-reflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and workup of GERD, and no single test alone can provide the entire clinical picture. Results of testing are combined to document the presence and extent of the disease and assist in planning the operative approach. Currently, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery (Jobe, et al). In this case, the patient has undergone much of this pre-operative assessment but clinically significant reflux has not been demonstrated. In addition, the value of the LINX device in this clinical setting is uncertain. The patients pH recording demonstrated normal DeMeester scores (off acid blocker therapy) and her video esophagram did not show active reflux. Further, her infrequent reflux events proved poorly correlative with chest symptoms, thus, her ongoing symptoms cannot be considered medically refractory to acid blocker drugs. Also, implantation of the LINX device must be approached with caution given the patients documented complaint of dysphagia and demonstrated hang-up of a barium pill on esophagram. All told, the request for LINX procedure 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. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 58-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Plan has denied this request indicating that the requested procedure is considered investigational for the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found there is a lack of randomized controlled trials comparing Linx with Nissen fundoplication or other standard surgical anti-reflux procedures. According to Sheu and Rattner the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. In addition, Loh and colleagues concluded that further studies are required to determine its long term outcomes and its relative efficacy as compared to other established treatments, Adverse events, such as erosion through the esophagus, have been reported since U.S. Food and Drug Administration (FDA) approval (Bauer, et al). 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, such as surgical fundoplication. Based on current literature and clinical guidelines, LINX is not likely to be more beneficial for treatment of the enrollees 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. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 64-year-old male enrollee has requested reimbursement for inpatient stay at telemetry level of care provided from 5/23/18 through 5/30/18. 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 at the time of admission, the patient had a low potassium and an elevated troponin level. He had multiple cardiac risk factors, including hypertension, diabetes mellitus, congestive heart failure and advanced renal disease. Given these risk factors and the severity of his infection and wounds, it was reasonable to admit him to a telemetry level of care for 24 hours. The initial 24 hours is sufficient time to check serial echocardiogram and cardiac enzymes and have a cardiology consultation. Furthermore, the potassium level was improved by 5/24/18. He did not have any chest pain or acute ischemia on admission, and after monitoring and serial enzymes/echocardiograms, he could have been treated at a lower level of care from 5/25/18 through 5/30/18. Therefore, inpatient stay at telemetry level of care provided from 5/23/18 through 5/24/18 was medically necessary for the treatment of this patient. The records fail to demonstrate the medical necessity of inpatient stay at telemetry level of care provided from 5/25/18 through 5/30/18.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The parent of a 17-year-old female enrollee has requested reimbursement for surgery performed on 6/22/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for treatment of the enrollees enlarged labia. A review of the record indicates that the enrollee presented to her provider on 4/27/17. The enrollee reported enlarged labia which caused her to wear panty liners daily so that the bulge would not be noticeable through her underwear. Due to pad usage, she developed chronic irritation with intermittent vaginal discharge. On 6/22/17, bilateral labia minora reduction was performed. The Health Insurer indicates that the services at issue were not medically necessary. Therefore, the Health Insurer has denied reimbursement for the services at issue.  At issue is whether the services at issue were medically necessary for treatment of the enrollees medical condition. I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 60-year-old female enrollee has requested authorization and coverage for a heart monitor (implantable ambulatory event monitor). The Health Plan has denied this request indicating that the requested device is considered investigational for treatment of the enrollees syncopal episodes. The physician reviewer found that based on the records provided the patient is a 60-year-old female with infrequent syncope recently resulting in head trauma and negative short-term evaluation for culprit arrhythmias. In this setting, prolonged monitoring for a dysrhythmic cause of the patients syncope is reasonable, appropriate and considered standard accepted practice in the medical community. Prolonged monitoring cannot be feasibly obtained with any monitoring device other than an implantable device such as a LINQ monitor. This approach has shown to be more effective than standard monitoring in identification of a cause and is now incorporated into current guidelines (Strickberger, et al; Krahn, et al; Brignole, et al). Therefore, the request for a heart monitor (implantable ambulatory event monitor) 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 device 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 2

A 60-year-old female enrollee has requested authorization and coverage for a heart monitor (implantable ambulatory event monitor). The Health Plan has denied this request indicating that the requested device is considered investigational for treatment of the enrollees syncopal episodes. The physician reviewer found the request for a LINQ device is likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. The patient has been extensively evaluated with two Zio Patch event monitoring periods in 2016 and 2017, neither of these studies demonstrated an etiology for recurrent syncope. In addition the patient has a structurally normal heart as well as a negative electrophysiologic study which failed to demonstrate inducible arrhythmias or periods of high grade atrioventicular block. In light of these facts other than an implanted loop recorder there is no other diagnostic modality that would likely be more helpful. As such, request for a heart monitor (implantable ambulatory event monitor) 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 device 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 60-year-old female enrollee has requested authorization and coverage for a heart monitor (implantable ambulatory event monitor). The Health Plan has denied this request indicating that the requested device is considered investigational for treatment of the enrollees syncopal episodes. The physician reviewer found the request for a heart monitor (implantable ambulatory event monitor) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The ILR is a non-invasive diagnostic device that is often of great clinical use in this clinical setting, since it can remain in place for long periods of time and provide information about arrhythmias when other techniques have not been revealing. In this case, the patient has syncope with head trauma and previous evaluation has not determined the cause of syncope. The patients symptoms are described as infrequent and the extensive work-up was performed years. The requested device is likely to provide better information than a 30-day monitor or any other type of monitor currently available. Moreover, the use of the ILR is in accordance with American College of Cardiology guidelines. For the reasons provided, the requested device 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 device 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 56-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees low back pain. The physician reviewer found the request for radiofrequency neurolysis is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is medical literature supporting the utility of radiofrequency neurolysis in this clinical setting. In addition, the patient was previously treated with radiofrequency ablation which provided pain relief which lasted almost 11 months. As such, the request for radiofrequency neurolysis 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 service 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 2

A 56-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees low back pain. The physician reviewer found the medical literature recommends using a pain diary to verify when the local anesthetic wore off for the treatment of diagnostic medial branch block prior to radiofrequency ablation (Derby, et al). According to the documentation available for review, the records do not document a pain diary. Moreover, it is unclear that she obtained significant benefit from the prior radiofrequency ablation. The record submitted does not support that she did obtain relief to corroborate improvement, with no mention of increased functional benefit from a baseline or decrease in perceived pain from a baseline. Therefore, the request for radiofrequency neurolysis 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 service 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 3

A 56-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees low back pain. The physician reviewer found the radiofrequency ablation is an accepted treatment that can be included in the standard of care when treating chronic back pain. The patient has symptoms consistent with facet mediated pain and has undergone prior radiofrequency ablation. She continues to perform an independent home exercise program and is limited in terms of medication tolerance. Recent imaging showed an improvement in the previous L5-S1 disc herniation consistent with the time since previous imaging as well as the patients commitment to exercise and conservative treatments. The two-level right-sided procedure proposed is supported by the patients reported symptoms. The patient had a positive response to radiofrequency ablation performed in December 2015. The current request for repeat radiofrequency ablation is more than six months after the prior treatment. Based on the clinical documentation submitted for review, the requested service 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 service 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.