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

Summary Reviewer 


A 63-year-old female enrollee has requested reimbursement for substance abuse inpatient detoxification and residential services provided from 9/26/16 through 10/20/16. 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 documentation provided does not support the medical necessity for the services at issue in this clinical setting.  By the time of the patients admission on 9/26/16, her last use of alcohol was on 9/21/16.  Although she was said to have experienced a seizure with subsequent hospitalization, there were no medical records provided from which to ascertain the nature and severity of this seizure or the treatment of same.  On admission to detoxification, she was not on any prophylactic anticonvulsant medication.  The patient did not demonstrate any post-acute withdrawal symptoms described in either the history and physical, or the psychiatric evaluation.  She was not a danger to herself or others.  There were no emotional, behavioral, cognitive, or impulsive factors requiring inpatient detoxification level of care.  She was not agitated, manic, or psychotic.  She suffered from hypertension and hyperlipidemia. However, neither these medications nor did the upwards titration of Lexapro, required inpatient monitoring.  She was underweight at 104 pounds but this was not a life threatening situation requiring 24 hours per day, seven days per week monitoring with medical, nursing, and dietary professionals.  The patient has a history of an extended period of sobriety, with Alcoholics Anonymous attendance. There is no evidence to suggest that she could not have continued her recovery at an ambulatory level of care.  Based on the records provided, this patient did not require 24 hours per day, seven days per week monitoring. As such, reimbursement for substance abuse inpatient detoxification and residential services provided from 9/26/16 through 10/20/16 were not medically necessary for the treatment of this patient. Therefore, based on the reasons stated above, the services at issue were not medically necessary for treatment of this patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

The patient is a 19-year-old female who developed symptoms of headache, lock jaw, bodily stiffness, dizziness and numbness in her legs and feet in late 2016. She was treated empirically for Lyme disease and underwent extensive testing for Lyme disease and other tick-borne diseases. The records report that the testing was unremarkable. The patient has requested reimbursement for infectious agent detection by nucleic acid, multiple organisms; amplified probe(s) technique, infectious agent detection by nucleic acid, not otherwise specified; amplified probe(s) technique, and each organism and methylenetetrahydrofolate reductase (MTHFR) inhibitor gene analysis, common variants testing provided on 7/5/17 and 9/19/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational. Overall, there is a lack of peer-reviewed medical literature to support the clinical utility of the polymerase chain reaction (PCR) and MTHFR testing as performed in this patients case. The MTHFR mutation assessment has not been shown to be of value in this clinical situation given this patients symptoms, or for use in diagnosing any tick-borne disease (Long and Goldblatt). Similarly, there is a lack of data supporting the use of Lyme PCR in making a diagnosis of this patients symptoms (Waddell, et al). All told, the infectious agent detection by nucleic acid, multiple organisms; amplified probe(s) technique, infectious agent detection by nucleic acid, not otherwise specified; amplified probe(s) technique, and each organism and MTHFR inhibitor gene analysis, common variants testing provided on 7/5/17 and 9/19/17 were 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 Upheld

Summary Reviewer 2

The patient is a 19-year-old female who presented to her provider with complaints of headache, lock jaw, dizziness and numbness. The documentation provided for review states the patient was treated for possible Lyme disease, but her symptoms persisted. The provider recommended further investigation for Vector-borne disease and rheumatoid diseases. The patient has requested reimbursement for infectious agent detection by nucleic acid, multiple organisms; amplified probe(s) technique, infectious agent detection by nucleic acid, not otherwise specified; amplified probe(s) technique, and each organism and methylenetetrahydrofolate reductase (MTHFR) inhibitor gene analysis, common variants testing provided on 7/5/17 and 9/19/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational. The appropriate laboratory testing for Lyme disease is with two-step testing, using first step EIA, and second step immunoglobulin G (IgG) and immunoglobulin M (IgM) immunoblots, if the first step is positive or equivocal. According to the guidelines of the Infectious Diseases Society of America (IDSA), use of polymerase chain reaction (PCR) of blood is not recommended in this clinical setting (Wormser, et al). PCR assay of blood has low sensitivity because of the short duration of spirochetemia (Lantos, et al). According to the Centers for Disease Control and Prevention (CDC), PCR testing of blood for Lyme disease lacks clinical sensitivity and has increased potential for contamination. The CDC noted that PCR on blood has not been universally standardized or optimized for diagnosis of Lyme disease (Moore, et al). Additionally, the MTHFR inhibitor gene analysis was not indicated. There was no history to suggest a hypercoagulable risk such as pulmonary embolism or deep venous thrombosis. Moreover, the current peer-reviewed medical literature has not established an association of this gene with hypercoagulable state or other clinical syndrome. Thus, MTHFR testing provided was not likely to be more beneficial for evaluation of this patients medical condition than any available standard testing.                                                                                                                                                             Given these findings, the infectious agent detection by nucleic acid, multiple organisms; amplified probe(s) technique, infectious agent detection by nucleic acid, not otherwise specified; amplified probe(s) technique, and each organism and MTHFR inhibitor gene analysis, common variants testing provided on 7/5/17 and 9/19/17 were 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 Upheld

Summary Reviewer 3

The patient is a 19-year-old female with recurrent headaches, lock jaw, body stiffness, dizziness, as well as complaints of numbness in her legs and feet. She was treated for possible Lyme disease per the documentation. Her symptoms persisted despite this treatment. The provider noted the patients presentation required further investigation for vector-borne disease and rheumatoid diseases. The patient has requested reimbursement for infectious agent detection by nucleic acid, multiple organisms; amplified probe(s) technique, infectious agent detection by nucleic acid, not otherwise specified; amplified probe(s) technique, and each organism and methylenetetrahydrofolate reductase (MTHFR) inhibitor gene analysis, common variants testing provided on 7/5/17 and 9/19/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational. Standard testing is recommended by Centers for Disease Control and Prevention (CDC) guidelines for Lyme disease, Babesia and well as Bartonella (Moore, et al). The provider noted concern was for vector-borne illnesses. The sensitivity and specificity for standard testing is appropriate for this patients constellation of symptoms. Thus, additional evaluation with polymerase chain reaction (PCR) or MTHFR testing was not indicated. Accordingly, the infectious agent detection by nucleic acid, multiple organisms; amplified probe(s) technique, infectious agent detection by nucleic acid, not otherwise specified; amplified probe(s) technique, and each organism and MTHFR inhibitor gene analysis, common variants testing provided on 7/5/17 and 9/19/17 were not likely to be more beneficial for the evaluation of the patients medical condition as compared to standard approaches.   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 Upheld

Summary Reviewer 1

A 38-year-old male enrollee has requested reimbursement for polymerase chain reaction testing for gastrointestinal pathogen panel performed on 12/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that most cases of acute diarrhea are due to infections and are self-limited. The major causes of acute infectious diarrhea include viruses, bacteria, and protozoa. For most patients who do not have severe illness or high-risk comorbidities, it is reasonable to continue expectant management for several days without microbiologic stool testing (e.g. polymerase chain reaction multiplex molecular panel tests). Per the Infectious Diseases Society of America (IDSA) guidelines, immediate testing is indicated with severe disease defined as follows: profuse watery diarrhea with signs of hypovolemia; passage of greater than six unformed stools per 24 hours; severe abdominal pain; need for hospitalization; other signs or symptoms concerning for inflammatory diarrhea; bloody diarrhea; passage of many small volume stools containing blood and mucus; temperature greater than or equal to 38.5AoC (101.3AoF). In this case, the submitted records do not document the severity and duration of symptoms. The clinical notes provided do not support that the patient met criteria for the services at issue. Therefore, polymerase chain reaction testing for gastrointestinal pathogen panel performed on 12/16/19 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 38-year-old male enrollee has requested reimbursement for polymerase chain reaction testing for gastrointestinal pathogen panel performed on 12/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The submitted records indicate that the patient had limited comorbidities at the time of the disputed testing, and that his diarrheal condition was self-limited and uncomplicated. Provided documentation fails to support fever, dysentery, severe dehydration, or that patient is an immunocompromised individual. Rather, the patientas record supports immunocompetency, no blood in stool, and a clinical history suggestive of a narrowly-focused infectious etiology. The medical evidence does not support the services at issue over otherwise targeted stool analysis for this patientas condition. Therefore, polymerase chain reaction testing for gastrointestinal pathogen panel performed on 12/16/19 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 38-year-old male enrollee has requested reimbursement for polymerase chain reaction testing for gastrointestinal pathogen panel performed on 12/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that the use of the gastrointestinal pathogen panel test is not supported in this case. The test is used to diagnose diarrhea, and there are several pathogens that can cause diarrhea. The American Academy of Family Practice guidelines for evaluation of acute diarrhea do not recommend the use of polymerase chain reaction assays at this time. Guidelines for the evaluation of diarrhea do not recommend nucleic acid panels in most cases either, and Riddle and colleagues stated, aIn addition, the significance of an identified organism may not be clear as these molecular technologies, which involve nucleic acid amplification, are limited to our existing knowledge of a microbesa genome and do not discriminate between viable and non-viable organisms. As a result, they can detect microbes at nonpathogenic levels. Given the high rates of asymptomatic carriage of enteropathogens, this can be a considerable problem. To confound matters, further multiplex techniques are more commonly associated with increased detection of mixed infections and the relative importance of each pathogen may be unclear.a Guidelines from the Infectious Diseases Society of America do not recommend the gastrointestinal pathogen panel in cases of diarrhea without severe diarrhea characterized by complications such as fever or hematochezia.  Therefore, polymerase chain reaction testing for gastrointestinal pathogen panel performed on 12/16/19 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 57-year-old male enrollee has requested authorization and coverage for implanted upper airway stimulation device (Inspire). The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees obstructive sleep apnea (OSA). The physician reviewer found that as noted in the current medical literature, OSA is an increasingly prevalent clinical problem with significant effects on both personal and public health. CPAP has demonstrated excellent efficacy and low morbidity. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA (Woodson, et al). The results of the STAR trial demonstrated the hypoglossal nerve stimulator to be safe and effective in a small subset of patients with OSA who have failed CPAP. In this case, the patient presents with a BMI of 31.2, AHI of 25.8 and nonconcentric airway collapse. He has also failed CPAP therapy. In this clinical setting, the request for implanted upper airway stimulation device (Inspire) has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 57-year-old male enrollee has requested authorization and coverage for implanted upper airway stimulation device (Inspire). The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees obstructive sleep apnea (OSA). The physician reviewer found that the request for implanted upper airway stimulation device (Inspire) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is some medical literature indicating that hypoglossal nerve stimulation for treatment of obstructive sleep apnea may have beneficial outcome with minimal adverse effect for selected patients. However, there are a lack of studies comparing data regarding outcomes of hypoglossal nerve stimulation to that of standard available therapy. Although the use of hypoglossal nerve stimulation for the treatment of obstructive sleep apnea is promising, the available medical literature is limited. Given the lack of definitive support in the peer-reviewed literature, implanted upper airway stimulation device (Inspire) is not likely to be more beneficial for treatment of the patients medical condition than standard available therapy. Based upon the information set forth above, the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 57-year-old male enrollee has requested authorization and coverage for implanted upper airway stimulation device (Inspire). The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees obstructive sleep apnea (OSA). The physician reviewer found that the requested device (Inspire) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Although the patient meets certain clinical criteria for implantation of a hypoglossal nerve stimulator, the records do not document that the patient has tried and failed other potential surgical options such as uvulopalatopharyngoplasty (UPPP). In addition, a record of the patients complete physical examination is not included and the clinical status of the patients tonsils are unknown. For the reasons provided, the implanted upper airway stimulation device (Inspire) device 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 device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 63-year-old male enrollee has requested reimbursement for the wearable cardioverter defibrillator provided on 11/5/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient was at a significant risk from sudden cardiac death. He benefited from risk reduction with the wearable cardioverter defibrillator provided on 11/5/14. An increase in the risk of sudden cardiac death, and a potential benefit from implantable cardioverter defibrillator (ICD) implantation, has long been recognized in patients with left ventricular dysfunction related to underlying ischemic heart disease. This patient was at risk for sudden cardiac death while awaiting improvement in left ventricular systolic function prior to consideration of a permanent ICD. Given the above, the wearable cardioverter defibrillator provided on 11/5/14 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 Overturned

Summary Reviewer 2

A 63-year-old male enrollee has requested reimbursement for the wearable cardioverter defibrillator provided on 11/5/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found that circumstance there is potential for recovery of left ventricular function over time with medical therapy and there was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time (>90 days) where continued left ventricular dysfunction (ejection fraction = 35%) is documented to persist in spite of appropriate treatment (Russo, et al).  A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. A prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explantation. In sum, the wearable defibrillator has not yet been demonstrated by existing scientific literature as 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 Overturned

Summary Reviewer 3

A 63-year-old male enrollee has requested reimbursement for the wearable cardioverter defibrillator provided on 11/5/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found that the wearable cardioverter defibrillator (LifeVest) was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the placement of a wearable cardioverter defibrillator was clinically indicated as the patient presented with underlying COPD and a new diagnosis of severe symptomatic congestive heart failure, and LV dysfunction. There is scientific literature of large case series, prospective registries, and from expert opinion supporting the services at issue. In this particular clinical situation, the patient had a severely depressed ejection fraction and needed further aggressive ongoing medical treatment of both congestive heart failure and COPD, which further delayed the planned cardiac mitral and aortic valve replacement surgery. All told, the wearable cardioverter defibrillator was indicated in this particular short-term clinical situation with support in the medical literature, until both the planned surgical and medical treatments for congestive heart failure could be optimized and the LV function could be reassessed. 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.