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

Summary Reviewer 1


A 43-year-old female enrollee has requested reimbursement for molecular pathology testing provided on 4/14/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees breast cancer. The physician reviewer found the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. This patient presents with a personal history of breast cancer diagnosed at a young age as well as a first-degree relative diagnosed with breast cancer at a young age. She has already been tested and found to be negative for BRCA1 and BRCA2. Given the young age of breast cancer diagnosis in both the patient and her mother a strong likelihood of an inherited mutation exists. Panel testing helps guide management of the patient in screening for additional cancers that may be more likely if an inherited mutation is found. Therefore, the molecular pathology testing provided on 4/14/16 was 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 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 43-year-old female enrollee has requested reimbursement for molecular pathology testing provided on 4/14/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees breast cancer.The physician reviewer found the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Per National Comprehensive Cancer Network (NCCN) guidelines for genetic/familial high risk assessment, patients with a personal and family history of a single inherited cancer are best served for testing for that syndrome. In this case, breast cancer is documented in the patient and her family member. There is no clinical indication for MyRisk hereditary cancer testing in the clinical setting of a single inherited cancer. All told, the molecular pathology testing provided on 4/14/16 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 Overturned

Summary Reviewer 3


A 43-year-old female enrollee has requested reimbursement for molecular pathology testing provided on 4/14/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees breast cancer. The physician reviewer found the molecular pathology testing provided on 4/14/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers (Brose, et al; Thompson and Easton). BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers (Liede, et al; Tai, et al; Ferrone, et al). In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. The Amsterdam criteria and the Bethesda consensus guidelines evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families. Notably, the Amsterdam criteria have low sensitivity in HNPCC detection so the Bethesda guidelines were developed (Umar, et al). However, these guidelines are highly focused on patients with colorectal cancer who have microsatellite instability although the occurrence of microsatellite instability in other Lynch syndrome associated tumors was discussed. The most common extracolonic tumors in Lynch syndrome are endometrial, ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral cancers. This patients family history is suggestive of a breast/ovarian cancer syndrome. The MyRisk panel is appropriate since the current clinical situation may be caused by several potential cancer-causing genes. Therefore, the testing at issue was 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 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 43-year-old female enrollee has requested reimbursement for surgery performed by a non-participating provider on 6/15/17. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees back pain. The physician reviewer found that the documentation provided does not support the services at issue in this clinical setting. The patient has a foot drop and previous lumbar surgery with scarring. At the time of presentation on 6/15/17, the patient could have been safely treated by an in Plan spine provider. There was no indication for fusion surgery by a non-participating provider at that time. The medical records did not show any evidence of lumbar fracture, instability, or tumor that would have necessitated the procedure at issue. Additionally, the records indicated that the patient was approved for a consultation with an in Plan spine surgeon. As such, the criteria for surgery on 6/15/17 were not met and the patient did not need out of network spine surgery. In sum, surgery performed by a non-participating provider on 6/15/17 was not medically necessary for treatment of this patients medical condition.
Therefore, for the reasons stated above, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 34-year-old male who has been diagnosed with ulcerative colitis. The patient has requested authorization and coverage for Simponi 100 mg every 21 days. The Health Insurer has denied this request and reported that the requested medication regimen is not medically necessary for the treatment of this patient.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication regimen. The randomized PURSUIT study showed that Simponi serum concentrations are proportional to dose, and higher Simponi concentration was associated with improved clinical outcomes. Studies have shown that dose escalation can recover response to therapy in a significant fraction of patients. One study showed recovery of response in 71% of ulcerative colitis patients undergoing Simponi dose escalation, and another demonstrated improvement in half of patients (Taxonera and Rodriguez, et al; Taxonera and Iborra, et al). In this case, the patient has failed the standard dose of Simponi, with symptoms of active disease, and elevated fecal calprotectin. Dose escalation can recover response and prevent complications, such as disease flare, hospitalization, toxic megacolon, and dysplasia with risk of colorectal cancer. Therefore, Simponi 100 mg every 21 days is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 




The parent of a 17-year-old female enrollee has requested reimbursement for psychiatric residential treatment center services from 10/6/15 through 12/31/15. 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 there is sufficient support for the services at issue in this clinical setting. Prior to RTC level of care, the patient tried and failed multiple different avenues of outpatient care and care at less restrictive levels. Her behaviors were escalating and had not abated with treatment at these less restrictive levels. The patient continued her adverse behaviors.  The behaviors had escalated to the point where she began abusing multiple different substances, exhibiting high risk behaviors, experiencing depression and suicidal ideation. She also exhibited a general lack of care for her present behaviors. The documentation noted that this patient was at serious risk of causing significant self-harm, whether intentional or accidental. The patient required continued supportive services with intensive individual, family and group therapies prior to being discharged into the community or at a lower level of care. As such, psychiatric RTC services from 10/6/15 through 12/31/15 were medically necessary for treatment of this patient. Therefore, for the reasons stated above, the services at issue were 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 21-year-old female enrollee has requested reimbursement for knee arthroscopy synovectomy performed on 12/20/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that Schindler concluded that arthroscopic excision of the entire plical fold becomes indicated in recalcitrant cases and once a plica has undergone irrevocable morphological changes. The procedure carries low morbidity, and results are universally good, especially if the plica is the sole pathology. Hufeland and colleagues concluded that arthroscopic resection of a symptomatic medial plica provides excellent clinical results in young patients. This patient presented on 12/20/17 with recalcitrant right knee pain and prominent medial synovial plica. She had failed to improve despite conservative treatment. She underwent right knee arthroscopy with medial synovial plicectomy excision, debridement and synovectomy on 12/20/17. Current evidence-based medical guidelines support arthroscopic surgical intervention in this clinical scenario for synovial plica resection/synovectomy. Increased synovial hypertrophy is typically associated with multicompartmental pathology, as in this case. Therefore, knee arthroscopy synovectomy performed on 12/20/17 was likely to have been more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 21-year-old female enrollee has requested reimbursement for knee arthroscopy synovectomy performed on 12/20/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that Arthroscopic resection is a very good option for medial plicae that do not respond to conservative treatment, and it must be initiated as a first option when cartilage damage is suspected. Prejbeanu and colleagues performed a large study of 267 patients who underwent symptomatic medial plica resection and had good results with long-term follow-up documented. There is sufficient support for the services at issue in this clinical setting. In sum, knee arthroscopy synovectomy performed on 12/20/17 was likely to have been more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 21-year-old female enrollee has requested reimbursement for knee arthroscopy synovectomy performed on 12/20/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that Synovial plica are folds in the lining of the knee joint which are sometimes sources of painful abrasion against the medial femoral condyle.  The meta-analysis by Gerrard and Charalambous noted arthroscopic surgical management of symptomatic medial knee plica results in favorable outcomes. Our results suggest that arthroscopic surgical excision should be considered as a treatment modality in patients with pathological medial plica disease of the knee either as a first-line treatment or when symptoms have not responded to non-surgical interventions. Partial synovectomy for resection of symptomatic plica is a standard procedure. This patient had substantial knee pain despite nonsurgical treatment. Thus, knee arthroscopy synovectomy performed on 12/20/17 was likely to have been more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 53-year-old female enrollee has requested reimbursement for a sleep study performed on 12/19/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees insomnia. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. The patient presented with obesity, snoring and insomnia. Sleep onset insomnia is not an indication for a sleep study. Patients with sleep onset insomnia have a long sleep latency and patients with clinically significant sleep apnea have a short sleep latency. Moreover, the patients Epworth Sleepiness Scale score was normal. Thus, the patient did not have hypersomnia. Hypersomnia is the cornerstone for a diagnosis of sleep apnea. In addition, there was no documentation of witnessed sleep apnea or awakening gasping for breath. Furthermore, the patient did not have sleep apnea per sleep study. Based on the medical records submitted and the peer-reviewed literature, the sleep study performed on 12/19/14 was not medically necessary for evaluation of the patients medical condition. For the reasons provided, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 
The patient is a 19-year-old male who has been diagnosed with Crohnas disease. The patient has requested authorization and coverage for Stelara injections 90 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. This denial is the subject of this appeal and determination. The physician reviewer found that the current medical literature supports the use of Stelara in this case. Stelara has been approved by the U.S. Food and Drug Administration (FDA) for Crohnas disease. Sandborn and colleagues performed a large randomized controlled trial that demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-to-severe Crohnas disease that was resistant to anti-tumor necrosis factor (TNF) therapy. The study by Kopylov and colleagues showed a 73.7% response in patients with anti-TNF-resistant Crohnas disease, and 80% of responders maintained remission for six months. A significant majority of these patients were able to discontinue steroids. The mechanism of Stelara (ustekinumab) is entirely different than that of immunosuppressants and anti-TNF medications, which the patient has failed. A recent study by Wils and colleagues demonstrated that a significant majority of patients who have failed an anti-TNF medication achieve and maintain response with Stelara. American Gastroenterological Association guidelines for the treatment of Crohnas disease recommend ustekinumab in patients with failure of an anti-TNF medication such as Remicade. In this case, Stelara can control disease and prevent further complications (such as need for surgery) in this patient with severe disease, currently uncontrolled disease, and prior complications such as fistula. Guidelines do not recommend Humira before the use of Stelara, or Humira as safer or more effective than Stelara for the treatment of Crohnas disease. Therefore, Stelara injections 90 mg/ml are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 16-month-old female enrollee has requested authorization and coverage for hourly pediatric nursing, 12 hours per day, seven days per week (S9123). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this medically fragile patient has a number of problems as a result of, and in addition to, her cloacal abnormalities, chronic kidney disease, and prematurity. The most important issue for her at this time, prior to completion of her reconstructive surgeries, is prevention of urinary tract infection and preservation of renal function. With the introduction of skilled nursing services, she has had no further significant urinary tract infections requiring parenteral antibiotics and hospitalization. She has been able to attend preschool to aid in her development and help her to catch up to her peers. The patients mother is the primary caregiver and has significantly modified her schedule in order to provide for the patients custodial needs. She does not have the necessary expertise, however, to provide for the patients skilled medical needs, including ostomy care and prevention of urinary tract infections. The requested skilled nursing services 12 hours daily 7 days per week are essential to this patients current health as well as to the future success of her reconstructive surgeries. Therefore, the requested hourly pediatric nursing, 12 hours per day, seven days per week (S9123), is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 39-year-old male enrollee has requested reimbursement for the surgery performed on 9/22/15. The Health Insurer has denied this request indicating that the surgery at issue was considered investigational for treatment of the enrollees degenerative disc disease (DDD) with herniations.  The physician reviewer found the medical records indicate that the patient has chronic back pain and multiple levels of lumbar degeneration. Two-level artificial disc replacement surgery remains experimental. The procedure is U.S. Food and Drug Administration (FDA) approved for only single level use. Outcomes and complications of two-level total disc replacement surgery remain unknown this time. More research is needed to confirm preliminary findings to determine whether the procedure has a role in treating patients with two-level disc disease. All told, there is inadequate data to support the surgery performed on 9/22/15 as likely to have been more beneficial for treatment of this patients medical condition than any available standard therapy. Based upon the information set forth above, the surgery at issue was 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 39-year-old male enrollee has requested reimbursement for the surgery performed on 9/22/15. The Health Insurer has denied this request indicating that the surgery at issue was considered investigational for treatment of the enrollees degenerative disc disease (DDD) with herniations.   The physician reviewer found the U.S. Food and Drug Administration (FDA) approval for the ProDisc-L total disc replacement states that this device is indicated for spinal arthroplasty in patients who are skeletally mature, have degenerative disc disease at one level in the lumbar spine from L3 to S1, have no more than grade 1 spondylolisthesis at the involved level, and have had no pain relief after at least six months of non-surgical treatment. The FDA indicates that this device should not be use in patients with isolated radicular compression syndromes, especially due to disc herniation. Yue and colleagues conducted a study 41 patients who underwent one-level versus two-level lumbar total disc replacement with five-year follow-up. The authors reported that the study was unable to identify statistical differences in all clinical and radiographical outcomes for patients who underwent one- and two-level ProDisc arthroplasty in a cohort from two centers. Delamarter and colleagues concluded, despite the relatively short duration of follow-up and design limitations, that two-level lumbar disc arthroplasty offers clinical advantages in terms of pain relief and functional recovery in comparison with arthrodesis. Longer-term follow-up is needed to determine the risks for implant wear and degenerative segment changes. Given the lack of peer-reviewed medical literature demonstrating superior health outcomes with total disc replacements with the ProDisc-L and Synthes devices, the surgery at issue was 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 surgery at issue was 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 39-year-old male enrollee has requested reimbursement for the surgery performed on 9/22/15. The Health Insurer has denied this request indicating that the surgery at issue was considered investigational for treatment of the enrollees degenerative disc disease (DDD) with herniations.  The physician reviewer found the current medical literature with regard to two level total disc replacement in the lumbar spine includes varying outcomes. In a recent article published by Trincat and colleagues, the authors noted that two-level lumbar disc replacement can improve spinal function while preserving its mobility but the procedure is fraught with risks and complications. Thus, longer follow-up is needed to evaluate the sustainability of the results and to detect any adjacent segment disease. A high-quality meta-analysis and health technology assessment concluded that there is insufficient evidence to draw extensive efficacy conclusions comparing artificial disc replacement with a broad range of recommended treatment options in the lumbar spine (Park, et al). All told, the efficacy remains uncertain and inadequate evidence exists to establish long-term benefits or safety. Thus, the surgery performed on 9/22/15 was 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 surgery at issue was 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.