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

Summary Reviewer 


An 18-year-old female enrollee has requested reimbursement for mental health residential treatment provided from 6/23/17 through 7/16/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that submitted documentation supports the medical necessity of the services at issue. The patient has an extensive psychiatric history involving multiple prior inpatient treatment programs. The patient had a serious suicide attempt on 5/26/17 with Ativan and Vodka, which can be a lethal combination. The patient has a history of self-harm and is impulsive. She was ambivalent about treatment goals. It appears that the patient decompensated in less restrictive settings. There is sufficient support for the services at issue in this clinical setting. The records indicate that the patient had failed less restrictive means for treatment. Thus, mental health residential treatment provided from 6/23/17 through 7/16/17 was medically necessary for the treatment of this patient. Therefore, 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 Overturned

Summary Reviewer 

The patient is a 57-year-old male who presented to the emergency department of Mercy Medical Center in Redding, California with complaints of nausea, vomiting, decreased oral intake and epigastric abdominal pain radiating to the back.  The patient has requested reimbursement for air ambulance transport provided on 10/16/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that in order for air medical transport to be medically necessary, all medical necessity criteria must be met. These criteria include: the patientas condition must be such that any form of transportation other than ambulance would be medically contraindicated; the individualas condition is such that time needed to transport by ground poses a threat to the patientas survival; the individual is transported to the nearest hospital with appropriate facilities for treatment; and there is a medical condition that is life-threatening. When transporting from one facility to another, the above criteria must be met, and the first hospital does not have the required services and facilities to treat the patient. Per the submitted documentation, this patient required an ERCP. Mercy Medical Center did not have gastroenterology services available to perform an ERCP. The documentation noted that California Pacific Medical Center a Van Ness was the closest facility with available gastrointestinal services. Time for ground transportation was at minimum 3 hours and 37 minute via a toll road. Generally, ground transport times greater than 30 minutes would justify the initiation of air transport. Transport by air took 1 hour and 28 minutes. There is sufficient support for air ambulance transport in this case. Therefore, air ambulance transport provided on 10/16/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 29-year-old female with Crohnas disease. The patient has requested authorization and coverage for Stelara (ustekinumab IV solution 130 mg/26 ml (5 mg/ml). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that this patient has moderate to severe Crohnas disease based on age below 30 at diagnosis. Per American Gastroenterological Association guidelines for therapy of moderate to severe Crohnas disease, immunosuppressants, such as azathioprine, 6-mercaptopurine, and methotrexate, are not recommended as primary monotherapy. For patients with moderate-severe Crohnas disease, immunosuppressants may take up to 17 weeks to be effective, and aminosalicylates, corticosteroids, and antibiotics are not recommended as long-term primary therapy as they are unlikely to prevent complications. American College of Gastroenterology guidelines also do not recommend immunosuppressants or methotrexate as primary monotherapy for the induction of remission of Crohnas disease, stating, aAzathioprine and 6-mercaptopurine are not more effective than placebo to induce short-term symptomatic remission and should not be used in this manner.a The guidelines do recommend Stelara as a primary monotherapy for the treatment of Crohnas disease. A large randomized controlled trial by Sandborn and colleagues demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohnas disease. Another study by Kopylov and colleagues showed a 73% response in patients with anti-tumor necrosis factor-resistant Crohnas disease, and 80% of responders maintained remission for one year. A significant majority of these patients were able to discontinue steroids. Therefore, Stelara (ustekinumab IV solution 130 mg/26 ml (5 mg/ml) is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 64-year-old female enrollee has requested reimbursement for gene testing performed on 10/30/17. 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 FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells, with the hope that it will identify a specific mutation or target that could guide the clinician as to which chemotherapeutic agent would be useful. However, there is a lack of convincing evidence that the assay adds to the decision-making ability or yields a result that is reliably clinically beneficial. A randomized study by Le Tourneau and colleagues did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the oncologists clinical judgment. Finding a mutation does not guarantee that a drug targeting that mutation will be beneficial. Multiple editorials have questioned the overall approach to treatment using such molecular panels. Therefore, gene testing performed on 10/30/17 was not likely to have been more effective than other available method for evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 64-year-old female enrollee has requested reimbursement for gene testing performed on 10/30/17. 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 understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing prognostic information, the value of next generation sequencing to predict candidates for specific mutation-driven treatment holds promise but is not yet ready for routine clinical use. Although the ability to decipher genomic aberrations in individual breast cancers to the single nucleotide resolution is now possible, there is a lack of data to show that this information can guide treatment decisions for patients with metastatic breast cancer. The use of next generation sequencing, such as with FoundationOne testing, continues to be the subject of ongoing clinical trials. In sum, gene testing performed on 10/30/17 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 64-year-old female enrollee has requested reimbursement for gene testing performed on 10/30/17. 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 next-generation sequencing, such as provided by FoundationOne is an appropriate medical diagnostic test for this difficult situation. It is medically appropriate to offer this patient the opportunity to participate in clinical trials. FoundationOne genetic testing is an accepted standard and appropriate diagnostic approach for the identification of clinical trials that would be suitable for this patient, based on tumor mutational analysis. At the time of testing in October 2017, metastatic breast cancer patients had targeted therapy options available through standard of care. Patients with BRCA mutations identified by genomic testing could pursue therapy with olaparib, which was demonstrated to be superior to standard chemotherapy. Additionally, patients with metastatic breast cancer can have tumor mutations for microsatellite instability and DNA mismatch repair, making them eligible for standard treatment with pembrolizumab. The use of FoundationOne testing is an appropriate diagnostic assay for the determination of eligibility for these approved therapies. Use of pathology tests with next-generation sequencing, including FoundationOne genetic testing, was likely to have be more beneficial for this patients medical condition than the choice of available standard therapies based on empirical therapeutic choice processes, as this has the possibility to identify therapies that may be more effective with less toxicity, or to identify potential candidacy for targeted clinical trials that may be provide greater benefit than empiric choice of chemotherapies. Thus, gene testing performed on 10/30/17 was likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 55-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the U.S. Food and Drug Administration has approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm. This patient meets those specific criteria. The device is a ring made up of a series of magnets that have sufficient attraction to increase the lower esophageal sphincter closure pressure, but allow for food passage with swallowing. Based upon a prospective study by Lipham and colleagues that included 44 patients, the mean total percent time that pH was less than 4 was reduced from 11.9 percent at baseline to 3.8 percent at three years. A recent study comparing the LINX procedure with laparoscopic fundoplication was performed by Reynolds and colleagues. The authors found that gastroesophageal reflux disease 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. Therefore, the LINX Reflux Management System (code 43284) and one inpatient day are likely to be superior over other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 55-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that appropriate patient selection is crucial before anti-reflux procedures. On 1/09/19, the patients provider noted the off-drug pH study comes back with normal DeMeester scores, and cannot substantiate the diagnosis of significant reflux. Per the records, upper endoscopy did not document significant reflux esophagitis either. Further, the patient cannot be considered medically refractory to maximally dosed acid suppression. Additionally, the records document significant esophageal dysmotility. The risks, medical appropriateness, or necessity of LINX in the setting of hypertonic esophageal motility disorder is not apparent. In this case, the requested services are not likely to be more beneficial for treatment of the patients medical condition than available standard therapy, such as weight loss, lifestyle modification, further characterization of lower esophageal reflux dysfunction, and maximal proton pump inhibitor use. In sum, the LINX Reflux Management System (code 43284) and one inpatient day are not likely to be of greater benefit than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 55-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found 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 also state that more evidence is needed before LINX can be recommended. Skubleny and colleagues concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia, requiring endoscopic intervention, which is a concern in this patient with hypertensive lower esophageal sphincter. 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, surgical fundoplication. Thus, the LINX Reflux Management System (code 43284) and one inpatient day are not likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 49-year-old female enrollee has requested authorization and coverage for endoluminal ablation. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees varicose veins. The physician reviewer found that the documentation supports the medical necessity of the requested endoluminal ablation. The patient is experiencing significant worsening edema in the right leg that limits her ability to perform activities of daily living despite conservative treatments including the use of medical grade compression stockings. In addition, the Duplex findings are remarkable with respect to the large size of the involved vein and the extensiveness of the reflux. Given these findings, the treatment plan is both appropriate and medically necessary. Based on the foregoing discussion, the requested services 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 33-year-old female enrollee has requested authorization and coverage for Xeljanz 5 mg tablets 60/30 days. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollee/s medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. This patient has failed alternatives, including multiple anti-tumor necrosis factor (TNF) medications. Xeljanz has a different mechanism of action than anti-TNF therapies and Entyvio. Xeljanz is U.S. Food and Drug Administration (FDA) approved (at up to 10 mg twice daily, with lower dosage for several factors) for the treatment of ulcerative colitis, and has proven to be effective in a double-blind, placebo-controlled trial of patients with moderate-severe ulcerative colitis. In this patient with severe disease and failure of multiple biologic medications of different classes, Xeljanz is medically indicated. Therefore, Xeljanz 5 mg tablets, 60 per 30 days are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 70-year-old male enrollee has requested reimbursement for an attended sleep study performed on 1/9/17. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was not medically necessary for evaluation of the enrollees obstructive sleep apnea (OSA). The physician reviewer found that there has been a shift in the provision of care from the attended setting to the ambulatory/home environment for sleep studies. This has been accomplished through the technological advancements associated with auto-titrating continuous positive airway pressure devices (APAP and AutoPAP). These devices are used to maintain a patent oropharynx in the treatment of patients with OSA. APAP devices titrate effective airway pressure throughout the night using an algorithm that responds to physiologic signals, allowing for use outside of a sleep center. Current medical literature including randomized studies has shown that the use of an AutoPAP produces an equivalent outcome to attended CPAP titrations (Rosen, et al; Berry and Sriram; Chai-Coetzer, et al). In this case, there was no documentation provided for review that AutoPAP was trialed. He was then referred for an attended CPAP titration. Nor did the patient have any comorbid medical conditions that would be expected or to degrade the quality of an AutoPAP in the home setting. The provision of services in the laboratory setting would be considered to exceed the clinical needs and services required for the effective management of the patients condition. Such services could have been provided in a less resource intense setting as well. For these reasons, the attended sleep study performed on 1/9/17 was not medically necessary for evaluation of the patients medical condition. Based on the foregoing discussion, 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 Upheld

Summary Reviewer 

A 19-year-old male enrollee has requested reimbursement for 84999 performed on 10/17/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines states while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical trial. Newer prognostic molecular techniques should not replace standard staging procedures.  In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Therefore, CPT 84999 performed on 10/17/18 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 33-year-old female enrollee has requested reimbursement for the residential mental health treatment services provided from 3/2/17 through 3/16/17. 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 modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general, community intervention settings optimize treatment gains while episodic placement in more restrictive settings can be clinically appropriate for patients with significant mental illness. The American Psychiatric Association (APA) states that the provider should determine the least restrictive setting for treatment that will be most likely not only to address the patients safety, but also to promote improvement in the patients condition. In this particular case, the patient presented with co-occurring bipolarity and anxiety. Patients with bipolar disorder spend a disproportionate time in the depressed phase. This is of particular relevance since it has been well-established in both clinical practice and the medical literature, such as the definitive Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, that anxiety-ridden mood disorders are difficult to treat and in general have poorer outcomes. Further, the patient had previously failed treatment in a less restrictive setting. Thus, the residential admission was indicated. During the disputed timeframe, the patient consolidated treatment gains and remained engaged in active treatment. However, discharge on 3/2/17 would have been premature and more than likely would have resulted in undue morbidity and re-admission. The services and setting were safe, appropriate and consistent with good practice, while the duration of the admission aligned with community standards. Additionally, the services provided were reasonably expected to improve her condition and prevent a more serious episode of illness. Considering the clinical presentation and perusal of the peer-reviewed literature, the residential mental health treatment services provided from 3/2/17 through 3/16/17 were medically necessary for treatment of the patients behavioral health condition. Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.