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

Summary Reviewer

The patient is a 43-year-old female with a history of left upper extremity, lower extremity and trunk pain. The provider reports the patients pain is consistent with complex regional pain syndrome (CRPS), autonomic nervous system dysfunction, and gastrointestinal dysfunction. The patient states that since starting treatment with neuromuscular stimulation therapy, she has begun to regain muscle that was atrophied. She can walk short distances without assistance. A 2/20/18 document from her provider reports that the patient had a left knee immobilizer and then crutches for several months which caused atrophy and leg weakness. On physical examination, there was weakness in her right L4, L5, and S1 myotomes and upper body myotomes in C5, C6 and C7. The provider recommended a system called Advanced Recovery Program which is neuromuscular stimulation therapy. The patient has requested authorization and coverage for neuromuscular stimulation therapy. The Health Insurer has denied this request indicating that the requested equipment is not medically necessary. There is a lack of trials demonstrating clinical benefit with neuromuscular electrical stimulation for chronic pain. Although the records indicate the patient has some weakness in the upper and lower extremity, there is no evidence of muscle atrophy on physical examination documentation. The provider states that a left knee immobilizer caused the patient atrophy. However, a knee immobilizer on the right is not likely to affect all of the unilateral left L4, L5, and S1 myotomes as indicated in the progress note. Additionally, the provider states the patient had leg weakness from using crutches, which does not explain the unilateral weakness. Moreover, there is no progress notes indicating muscle atrophy on a physical examination. Overall, the available documentation does not support the requested neuromuscular stimulation therapy as medically necessary for treatment of this patients medical condition.  Based on the foregoing discussion, the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 72-year-old male enrollee has requested reimbursement for Oncotype DX Prostate Cancer Assay performed on 4/21/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for evaluation of the enrollees prostate cancer. The physician reviewer found there currently are three major approaches to the management of localized prostate cancer. These include surgical prostatectomy, radiation therapy, and active surveillance.  Recommendations are made as to these options based on risk stratification, which estimates the risk for the future development of progressive cancer. The patients cancer is evaluated with a combination of clinical features, prostate-specific antigen, and pathologic details, particularly Gleason cancer grade.  By such a method, patients can be placed into four general categories: very low risk, low risk, intermediate risk, and high risk. Therapeutic recommendations will then depend on this risk classification. By this methodology, this patient would be classified as very low risk, for whom surveillance only would be the recommendation. A further refinement of prognostication is the use of gene panels, such as Oncotype DX Prostate Cancer Assay. This is a panel of 17 genes that may assist in predicting recurrence after treatment for prostate cancer. It is being used to some degree in localized cancer as a possible aid in decision making. However, in this setting of a very low risk patient, it has not been clinically validated as ultimately clinically beneficial. In this patients case, the services at issue were not medically indicated given his very low risk cancer. Thus, Oncotype DX Prostate Cancer Assay performed on 4/21/17 was not medically necessary for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 35-year-old female has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation provided from 9/15/16 through 4/17/17.  The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees major depressive disorder. The physician reviewer found that on the information provided, it appears that the TMS is being used for maintenance or continuation purposes, which is consistent with an investigational application.  A typical course of TMS consists of 30 to 40 sessions spanning four to six weeks.  For patients who respond well to TMS, clinical improvement is usually maintained with psychotherapy and psychotropic medication.  Although small studies are demonstrating good tolerability and clinical efficacy of TMS therapy for treatment courses lasting years at a time, according to the summary of TMS treatment recommendations authored by Perera and colleagues, The standard parameter setprovided clinical benefit in treatment courses up to six weeks in duration. Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established.  In other words, at this time there is a lack of well-designed and adequately-powered controlled studies showing the benefit of longer courses of TMS therapy.  Therefore, the superior efficacy of maintenance TMS therapy as compared to other available standard therapy, such as ongoing pharmacotherapy, psychotherapy and electroconvulsive therapy, has not been established.  Based upon the information set forth above, the services at issue were not and are 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 2


A 35-year-old female has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation provided from 9/15/16 through 4/17/17.  The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees major depressive disorder. The physician reviewer found the records document ongoing and unremitting major depressive disorder with multiple hospitalizations for suicide attempts and ongoing suicidal ideation.  She has tried and failed antidepressants from different categories, for adequate duration and at adequate dosage.  Augmentation was attempted, which also failed.   Psychotherapy, in a variety of modalities, provided little relief as well.  She received an initial course of TMS, with dramatic improvement.  Given that she showed a dramatic improvement in symptom reduction, with rapid return of depressive symptoms on discontinuation of treatment, she required a maintenance course. Based upon the degree of treatment refractory depression, and that she has shown this level of responsiveness to treatment, further TMS treatment is appropriate.  Thus, TMS provided from 9/15/16 through 4/17/17 was and is likely to be of greater benefit than other treatment options.  Based upon the information set forth above, the services at issue were and 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 Upheld

Summary Reviewer 3


A 35-year-old female has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation provided from 9/15/16 through 4/17/17.  The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees major depressive disorder. The physician reviewer found this patient received 36 treatments prior to the Health Insurers denial.  At this time, the literature on TMS is not clear on whether maintenance treatment is an evidence-based treatment.  The literature indicates that continued treatment can and should occur if an initial response to TMS is not apparent.  However, in this case, the patient did show an initial response to TMS treatment.   The records indicate that the patients symptoms had improved during the initial TMS treatment period.  Since the patient showed benefit from acute/initial TMS treatments and given the lack of evidence for maintenance TMS treatments, the superior effectiveness of the services at issue has not been established.  Based upon the information set forth above, the services at issue were not and are 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 1


A 68-year-old female enrollee has requested DecisionDX melanoma assay test performed on 6/19/15.  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 there is sufficient support for the services at issue in this patients case.  DecisionDx is a study of 15 to 31 genes in the melanoma cells.  It has been used to classify the patients melanoma as having high or low risk of metastasis.  There is much controversy as to its value in cutaneous melanoma when compared to the more usual prognostic factors.  However, it does appear to be particularly useful in the analysis of prognosis for uveal melanomas, and this has been validated in several studies.  This testing has become a standard in many ocular cancer centers.  Its clinical value lies in the fact that it implies no real need for surveillance for metastasis in those with a low risk of metastasis, whereas those with a higher risk should undergo more intense surveillance and perhaps be considered for adjuvant therapy.  All told, DecisionDX melanoma assay test was likely to have been more effective 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 Overturned

Summary Reviewer 2


A 68-year-old female enrollee has requested DecisionDX melanoma assay test performed on 6/19/15.  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 clinical setting.  The DecisionDx melanoma assay test is considered a standard of care for determining if adjuvant therapy is needed to treat patients with uveal melanoma. Using samples of primary uveal melanomas obtained by fine needle biopsy, tumors are classified as having low (class 1) or high (class 2) metastatic potential, depending on the expression of 15 genes.  In sum, the DecisionDX melanoma assay test was likely to have been more efficacious 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


A 68-year-old female enrollee has requested DecisionDX melanoma assay test performed on 6/19/15.  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 this patient has a rare disease, ocular melanoma, which has a poor prognosis once it metastasizes.  However, knowledge of the propensity for metastasis directly affects surveillance of patients by computed tomography (CT) scan.  The gene expression classifier DecisionDX defines two classes of ocular melanoma. Class I is associated with a low risk of metastasis and class 2 has a 50% risk at two years and 72% risk at five years.  There is no other standard prognostic indicator that could serve as an alternative. Thus, the current medical evidence favors the use of this test in the postoperative surveillance of patients with ocular melanoma.  In sum, the DecisionDX melanoma assay test was likely to have been of greater efficacy 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 35-year-old female enrollee has requested reimbursement for DecisionDx Melanoma testing performed on 1/16/19. 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 has an early stage melanoma. The National Comprehensive Cancer Network guidelines state that 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 study. 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, the DecisionDx-Melanoma test performed on 1/16/19 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 42-year-old female who has been treated for the following conditions: low back pain; other intervertebral disc degeneration, lumbosacral region; other intervertebral disc degeneration, lumbar region; radiculopathy, lumbar; other spondylosis, lumbar region; other intervertebral disc displacement, lumbar region. The patient has requested authorization and coverage for spinal surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.  The physician reviewer found that Bydon and colleagues noted, aA trial of conservative therapy may be considered for patients with low-grade spondylolisthesis presenting with radiculopathy and/or pseudoclaudication. These options may include physical therapy, epidural steroid injection, and pain medications. If unresolved, surgical options may include decompression alone or decompression and fusion.a Chan and colleagues stated, aPatients with symptomatic lumbar spondylolisthesis may first be treated with conservative management strategies including, but not limited to, non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy. For well-selected patients who fail conservative management strategies, surgical management is appropriate.a  In this patientas case, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures prior to requested surgery to include (but not limited to) physical therapy measures. In addition, she is noted to be a daily tobacco user and notes she will quit nicotine; however, follow-up documentation does not indicate this has been completed. The provided imaging studies, including the dynamic x-rays from 8/10/21, do not corroborate movement/instability at the requested level, and detailed documentation is not evident regarding potential impending/inevitable temporary intraoperative instability. There is a lack of support for the requested services in this clinical setting. Therefore, the requested spinal surgery is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 42-year-old female enrollee has requested reimbursement for emergency room and related services provided on 4/10/15. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found that the  issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition on the date in dispute. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with a sudden onset low back and flank pain, nausea, and dizziness. There are many serious medical conditions which may cause similar intense symptoms. These range from acute ureterolithiasis, aortic dissection, appendicitis, perforated viscous, pyelonephritis, herniated disc, and ovarian torsion.  The patient attempted to treat her condition with ibuprofen at home. When that failed, she sought emergency medical evaluation. The etiology of the patients pain was unclear to the emergency physician and a thorough evaluation was performed to determine the cause of the symptoms. In sum, a prudent layperson would have sought medical attention on the date of service in question because the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. All told, the services provided on 4/10/15 met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


An 18-year-old male enrollee has requested reimbursement for residential treatment center (RTC) services provided from 2/1/15 through 3/24/15 and intensive outpatient program (IOP) services provided from 3/25/15 through 9/25/15. 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 2/1/15 through 3/24/15 and IOP services from 3/25/15 through 9/25/15 were medically necessary for treatment of the patients medical condition. The patients therapist recommended treatment at a residential facility due to increasing self-harm and suicidal ideation. The patient was initially admitted to the RTC level of care and then stepped down to IOP after he successfully completed each step. The services at issue were medically necessary for the development of strong bonds, therapeutic relationships and modeling types of behavior from which the patient himself can learn and emulate. In addition, the services provided were consistent and beneficial for treatment of the patients medical condition. Given the above, the services at issue were medically necessary for treatment of the patients medical condition. 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 Upheld

Summary Reviewer 


A 33-year-old female enrollee has requested reimbursement for the unlisted chemistry procedure (Decision Dx testing) provided on 10/30/15. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees cutaneous melanoma. The physician reviewer found the unlisted chemistry procedure (Decision Dx testing) provided on 10/30/15 was not medically necessary for evaluation of the patients medical condition. Decision Dx testing was developed from ocular melanoma samples and it has not been established in the peer-reviewed literature that this data applies to cutaneous melanoma as well. Use of this testing is not considered the standard of care. The National Comprehensive Cancer Network (NCCN) guidelines recommend that Decision Dx testing should not be performed outside of a clinical trial setting. Based on the lack of support in the peer-reviewed literature and national guidelines, the testing at issue has not been established as medically necessary for evaluation of the patients melanoma. Therefore, the testing at issue was not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 71-year-old male enrollee has requested reimbursement ablation of the prostate, transrectal high intensity focused ultrasound (HIFU) including imaging guidance performed on 12/20/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee who has a history of prostate cancer. The physician reviewer found that the patient is a 71-year-old male with a recurrence of prostate cancer with T2c predominantly Gleason 7 (4+3) cancer. The patient has requested reimbursement for the ablation of the prostate using transrectal HIFU including imaging guidance performed on 12/20/17. The Health Insurer has denied this request on the basis that the services at issue were considered investigational for treating this patients medical condition.There are some studies to support the efficacy of HIFU for early recurrence of prostate cancer when prostate specific antigen is less than 4 and a focal recurrent site is evident and low Gleason score is predominant. However, in this patients case, he has a recurrence of prostate cancer with a Gleason score of 7. In this case, use of HIFU was not likely to have been superior to other available techniques. While there is emerging data for its use in some patients, the current data has not shown its superiority over other salvage techniques. Therefore, the ablation of the prostate using transrectal HIFU including imaging guidance performed on 12/20/17 was not likely to have been superior over the available treatment options for this patient.Based upon the information set forth above, the services at issue were 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.