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

Summary Reviewer 2

A 23-year-old male enrollee has requested authorization and coverage for powered robotic lower body exoskeleton system. The Health Insurer has denied this request and reported that the requested device is not medically necessary for the treatment of the enrolleeas medical condition. The physician reviewer found that there is a lack of support for the requested device in this clinical setting. Knezevic and colleagues stated that exoskeleton assisted walking training improved oxygen uptake efficiency and walking velocities with a lower perception of exertion. However, there was no comparison with other forms of exercise that did not require the use of exoskeletons. Additionally, there was no demonstration of improved health outcomes. Van Dijsseldonk and colleagues stated that participants with complete spinal cord injury reported satisfaction with the exoskeleton for exercise and social interaction in the home and community, but report limitations as an assistive device during daily life. Additionally, there was no comparison with other forms of exercise that did not require the use of exoskeletons. Hong and colleagues identified that the training was safe, feasible, and effective. Most participants improve their walking velocity and distances with the progression of sessions. However, there was no identification of improvement of function or improved health outcomes as a result of this intervention. Many of the studies provided for review had extremely small sample sizes, significant conflicts of interest, no control/comparison group, were focused primarily on exoskeletons during the rehabilitation phase, or did not identify long-term sustained improvement in function or health outcomes as a result of home/community use of an exoskeleton device. Therefore, the requested powered robotic lower body exoskeleton system is not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 23-year-old male enrollee has requested authorization and coverage for powered robotic lower body exoskeleton system. The Health Insurer has denied this request and reported that the requested device is not medically necessary for the treatment of the enrolleeas medical condition. The physician reviewer found that a review of the literature does not reveal that the ReWalk exoskeletal system provides greater benefit for this patientas condition over the current standards of care for patients with this condition. There is a lack of long-term evidence that this device is more beneficial than standard rehabilitation methods. There is insufficient scientific evidence that this device has long-term positive effects on health outcomes. Although the device is reported to provide positive effects in terms of spasticity and pain outcomes and possible potential to improve bone metabolism and bowel/bladder functions, the studies performed on the ReWalk were limited in sample size and lack of long-term follow up. Efficacy still needs to be demonstrated in larger long-term studies. More research is required on walking performance compared to other mobility and training devices. Additional larger clinical trials over a long-term period are needed to provide additional information that would indicate that this system is superior to other methods of locomotion in paraplegic patients or that this exoskeletal system can prevent long-term complications in the spinal cord injury population. Therefore, the requested powered robotic lower body exoskeleton system is not likely to be more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 65-year-old female enrollee has requested reimbursement for the repair of nasal vestibular stenosis performed on 7/28/17. The Health Insurer has denied this request indicating that the surgery at issue was not medically necessary for treatment of the enrollees chronic sinusitis. The physician reviewer found nasal valve collapse is a common cause of nasal airway obstruction. Although many techniques have been devised to correct the functional and aesthetic aspects of this problem, none have been demonstrated to be uniformly successful. One solution to the problem may lie lateral to the nasal valve angle in the fibroareolar tissue that connects the lateral aspect of the lateral crus to the bony pyriform aperture. Age-related or surgically induced weakening and loosening of these structurally important, fibroareolar connections can result in a prolapse of the lateral aspect of the lateral crural away from the pyriform margin and toward the septum with a consequent narrowing of the nasal valve region. This narrowing can lead to nasal obstruction. This patient had valve collapse and a positive Cottle maneuver. Thus, the vestibular stenosis repair should improve her nasal breathing. Accordingly, the repair of vestibular stenosis performed on 7/28/17 was medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the surgery at issue was 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 48-year-old female enrollee has requested authorization and coverage for implantation of Strattice. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees abdominal hernia. The physician reviewer found that there is support in the literature for the efficacy of the requested services in this clinical setting. Based on the overall documentation provided for review, the patient has failed standard therapy for correction of her complex abdominal hernia.  She has failed primary repair with synthetic mesh, as the mesh had become infected and had to be removed. This patient has evidence of a symptomatic, recurrent, left lower abdominal hernia.  She has a history of severe trauma and multiple reconstructive procedures of her abdomen.  She has noted to have failed previous mesh placement, as it had become infected and had to be removed.  Currently, she is symptomatic from her hernia with chronic pain, treated with an abdominal binder and chronic opioid use.  The requested Strattice (porcine biologic mesh) is used to reinforce the abdominal reconstruction provided by autologous tissue.  Strattice is a bioprosthetic porcine mesh. The medical literature indicates that bioprosthetic materials are preferred over synthetic materials for use in contaminated fields and should be strongly considered when the defect has bacterial contamination.  Patel and colleagues noted, Strattice is an effective adjunct to AWR (abdominal wall reconstruction) when used as reinforcement during CS (component separation) for a wide variety of indications. Complication rates remain low in complex patients. In addition, Strattice appears to add durability to midline reconstructions with no recurrences during the follow-up period.  In summary, this patient has exhausted standard therapy and Strattice has been shown to provide benefit in abdominal wall reconstruction. As such, implantation of Strattice is likely to be superior to the standard options available for treatment of this patients medical condition.Therefore for the reasons stated above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 48-year-old female enrollee has requested authorization and coverage for implantation of Strattice. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees abdominal hernia. The physician reviewer found that based on peer reviewed medical literature, Strattice is an effective product for treatment of abdominal wall hernias and is available in a size appropriate for the patients condition. Strattice is a non crosslinked decellularized porcine xenograft which is comparable to Alloderm, a decellularized human allograft. Patel and colleagues (2011) reported a study of 78 complex patients with component separation abdominal ventral hernia repair with Strattice reinforcement. There was 12% exposure rate, but all patients went on to complete healing without explantation. They concluded that Strattice is an effective adjunct to abdominal wall reconstruction (AWR) when used as reinforcement in component separation ventral hernia repair. Patel and colleagues (2013), in a review of 41 patients with complex AWR and Strattice underlay from 2007-2010, state that all patients achieved abdominal wall closure with no recurrent hernias or need for Strattice removal. They concluded that patients with multiple comorbidities at intermediate risk of postoperative complications can achieve successful, safe AWR with Strattice. All told, implantation of Strattice is likely to be more effective than the standard options available for treatment of this patients medical condition. Therefore, for the reasons stated above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 48-year-old female enrollee has requested authorization and coverage for implantation of Strattice. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees abdominal hernia. The physician reviewer found that the patient has a large area of abdominal wall weakness. Component separation (CS) reinforced with Strattice or porcine acellular dermal matrix (PADM) has shown favorable results for ventral hernia repair. Per a study by Richmond and colleagues, CS/PADM reinforcement should be strongly considered for the repair of significant midline ventral hernia defects.  According to another recent study by Richmond and colleagues, Biologic materials have made it such that ventral hernias can be safely repaired after bowel surgery without increased risk of complications.  Finally, a study by Huntington and colleagues note, In 223 ventral hernia repair performed with biologic mesh at a tertiary care institution, Strattice, a porcine acellular dermal mesh, had significantly lower odds of hernia recurrence compared with AlloMax, FlexHD, and XenMatrix. Choice of biologic mesh affects long-term postoperative outcomes in ventral hernia repair.  The medical studies show that use of Strattice may decrease recurrence and increase the likelihood of a successful repair. This patient has documented failure with synthetic mesh. As such, the medical literature as well as this patients failure with other options support the use of Strattice in this clinical setting.  Accordingly, Strattice is likely to be a more effective treatment option than the available standard alternatives for this patient.Therefore, for the reasons stated above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 57-year-old female with a history of chronic back pain, anxiety and hypertension. She presented to her primary care provider on 12/21/20 for a physical examination. The physician reviewer found that the clinical manifestations of vitamin D deficiency depend upon the severity and duration of the deficiency. The majority of patients with moderate to mild vitamin D deficiency are asymptomatic. With severe vitamin D deficiency, there can be hypocalcemia, which leads to bone disorders. Patient groups who are at risk for vitamin D insufficiency include those who have dark skin or are obese, those taking medications that accelerate the metabolism of vitamin D, hospitalized or institutionalized people, and patients who have limited effective sun exposure. Other people at high risk include those with osteoporosis or malabsorption, including inflammatory bowel disease and celiac disease. Screening of the general population is not recommended. Normal-risk adults do not need assessment. In this case, the records did not document any chronic medical conditions that would cause vitamin D deficiency or symptoms associated with vitamin D deficiency. There is a lack of support for the services at issue in this clinical setting. Therefore, vitamin D testing performed on 12/21/20 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 61-year-old male enrollee has requested reimbursement for genetic testing (81201, 81210, 81211, 81235, 81292, 81295, 81298 and 81321) performed on 2/13/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees metastatic colon cancer to the lung. The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue. It has not been established if molecular markers are useful in treatment determination (predictive markers) and prognosis other than for KRAS, NRAS, and BRAF mutation testing, microsatellite instability, and mismatch repair testing. Multiple clinical trials that are attempting to validate this personalized or precision medicine approach are in various stages of development and execution. Although preliminary data from some of these efforts have fueled excitement about the utility of these studies, their execution has also provoked many questions about the best way to approach complicating factors, such as tumor heterogeneity and the choice of which genetic mutations to target. Currently, it is unclear if molecular profiling is beneficial in identifying potential targets for treatment. Additionally, if targets are identified, it is unclear if targeted treatment is beneficial. In this patients case, the current evidence supports a portion of the services at issue. Specifically, 81210 (BRAF), 81235 (EGFR gene analysis, common variants), 81292 (MLH1 gene full sequence), 81295 (MSH2 gene full sequence) and 81298 (MSH6 gene full sequence) were medically necessary for the evaluation of this patient. However, the medical necessity of the remaining tests performed has not been established. Therefore, a portion of the services at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 60-year-old male enrollee has requested reimbursement for the subtalar arthrodesis provided on 11/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees hallux valgus. The physician reviewer found that this patient presents with an adult onset painful flatfoot and hallux valgus. The treatment under review had been successfully used on the other foot, which consisted of a calcaneal osteotomy, subtalar arthroereisis and tight wire management of hallux valgus. As isolated arthroereisis has limited benefit, when accompanied by other flatfoot correcting procedures, it has the ability to provide better results than attempting the subtalar blocking procedure alone. This patients care included a soft tissue hallux valgus tethering with rear foot re-orienting. In concert with the calcaneal osteotomy, a second procedure increases the potential for an improved result. The subtalar implant is not a procedure that should be performed alone and it does have complications but it appears to have the potential to provide a better outcome. Thus, the subtalar arthrodesis provided on 11/23/15 was 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 services at issue were 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 60-year-old male enrollee has requested reimbursement for the subtalar arthrodesis provided on 11/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees hallux valgus. The physician reviewer found that calcaneal osteotomy has been demonstrated to be an effective procedure to control a painful flat foot. However, the concurrent procedure, subtalar arthroereisis, has not been demonstrated in large, randomized controlled clinical trials to provide long-term benefits beyond that anticipated with conservative measures. The data on subtalar arthroereisis in the published medical literature is inadequate to draw scientific conclusions. All told, the subtalar arthrodesis provided on 11/23/15 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 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.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 60-year-old male enrollee has requested reimbursement for the subtalar arthrodesis provided on 11/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees hallux valgus. The physician reviewer found that the enclosed information and available literature on subtalar arthroereisis for the treatment of adult flexible flat foot do not demonstrate that the subtalar arthrodesis provided on 11/23/15 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. According to the medical literature, subtalar arthroereisis demonstrates good efficacy in re-aligning the subtalar joint, and reducing overpronation. However, there is a lack of large population studies to examine the efficacy of this procedure in reducing foot pain. Further studies are also needed to evaluate the long-term efficacy of this implant as it sits in the subtalar joint for many years. Long range analysis of side effects must be studied as well. Currently orthotics, Ritchie braces, and Arizona braces are standard of care for pathologic subtalar joint overpronation and its associated pain. 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.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 37-year-old male enrollee has requested authorization and coverage for placing devices in neck (insertion of more than one artificial intervertebral disc).  The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition.  The physician reviewer found that the requested services are not likely to be more effective for this patient than other available options. Based on the documentation submitted for review, the patient has left upper extremity symptoms and subtle findings of a cervical radiculopathy (Polston) with mild left triceps weakness and no atrophy/loss of sensation, nor reflex changes. In addition, two level artificial disc replacement remains controversial. The study by Davis and colleagues is a promising study but lacks long term safety and effectiveness data to make conclusions. There is a lack of randomized, prospective, scientific studies that have shown the long term safety and effectiveness of the proposed procedure. All told, the requested neck surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


A 37-year-old male enrollee has requested authorization and coverage for placing devices in neck (insertion of more than one artificial intervertebral disc).  The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition.  The physician reviewer found that the requested neck surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Two level total disc arthroplasty has become accepted by the community of spinal surgeons, both neurosurgeons, and orthopedists, to be superior in most instances, to a two level fusion. There is a growing body of evidence in the peer-reviewed literature that demonstrates two level total disc replacement is associated with a lesser incidence of adjacent level disease than a two level anterior cervical fusion. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 37-year-old male enrollee has requested authorization and coverage for placing devices in neck (insertion of more than one artificial intervertebral disc).  The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition.  The physician reviewer found that at this time, there is insufficient data to adequately assess the performance of total disc replacement. There is a lack of evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. Total disc replacement has been associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been fully documented. In this case, the patient has cervical spondylosis with foraminal impingement at the C5-6 and C6-7 levels. In this clinical setting, the standard procedure is a single level anterior cervical discectomy and fusion. In addition, the use of total disc arthroplasty in the setting of spondylosis with foraminal compromise by disc osteophyte complex and degenerated disc remains controversial.  Given the above, the requested neck surgery 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 services 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.