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

Summary Reviewer 3

A 48-year-old female enrollee has requested authorization and coverage for reconstructive lymphedema surgeries and one (1) inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. At issue is whether the requested services are likely to be more beneficial for treatment of the enrolleeas condition than any available standard therapy. The physician reviewer found that vascularized lymph node transfer is commonly performed in cancer centers to treat lymphedema. Postmastectomy lymphedema can be a difficult problem to manage. Compression therapy is the mainstay of treatment, but the medical literature indicates that microsurgical lymph node transfer or lymphaticovenous anastomosis provides better control of edema when compared to compression. Saaristo and colleagues found lymph node transfer improved lymphedema in the majority of patients and eliminated the need for physiotherapy and compression in one-third of the affected women. The authors concluded, aSimultaneous breast and lymphatic reconstruction is an ideal option for patients who suffer from lymphedema after mastectomy and axillary dissection.a Granzow and colleagues noted, aWhen applied appropriately to properly selected patients, surgical procedures used in the treatment of lymphedema are effective and safe.a The medical evidence supports the requested services in this patientas case. Therefore, reconstructive lymphedema surgeries and one (1) inpatient bed day are likely to be more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 57-year-old female enrollee has requested reimbursement and prospective authorization and coverage for chemical dependency residential treatment provided from 2/15/19 through 2/20/19. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The American Psychiatric Association indicates that residential treatment may be indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. Patients require safe and stable living environments in order to develop their recovery skills. The purpose of detoxification is to make the patient physically stable and safe. Rehabilitation is the essential component that should follow detoxification in order to help the patient maintain sobriety and reduce the risk of relapse. Given the severity of the patients illness, including her continuing to consume alcohol despite severe hepatic impairment while on a liver transplant waitlist, residential treatment was in accordance with generally accepted standards of medical practice and clinically appropriate for the patients illness. Therefore, chemical dependency residential treatment provided from 2/15/19 through 2/20/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 63-year-old female enrollee has requested authorization and coverage for Harvoni.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, cirrhotic genotype 1 patients who have failed PEG-interferon and ribavirin patients should be treated with Harvoni for 24 weeks.  These guideline recommendations are based on multiple randomized clinical trials. Studies have shown decreased survival with delayed treatment (Jezequel, et al).  All told, the requested medication is 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 55-year-old male enrollee has requested authorization and coverage for Lantus Solostar. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees type 2 diabetes and hyperlipidemia.   The physician reviewer found that Lantus was the first once-daily, long-acting insulin analog to be introduced more than 10 years ago and is specifically designed to provide basal insulin requirements (Hilgenfeld, et al). Manufacturers of insulin products for diabetes therapy have long sought ways to modify the absorption rate of exogenously administered insulins in an effort to better reproduce the naturally occurring pharmacokinetics of endogenous insulin secretion (Heise and Mathieu). Recent studies have demonstrated that newer basal insulins, such as Levemir have similar efficacy to that of Lantus (Dailey, et al). This patients records do not document that an adequate trial of Levemir has been performed or that the patient has a contraindication to this formulation. Thus, the requested Lantus Solostar is not supported as medically necessary for treatment of this patients type 2 diabetes. Based on these findings, the requested medication 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 31-year-old transgender female enrollee has requested reimbursement for facial feminization surgeries (21139, 14041, 21122, 30420, 15839 and 31899) performed on 11/16/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gender dysphoria.  The physician reviewer found that based on the medical documentation provided including a review of the photographs, the services at issue were not medically necessary. Facial feminization and tracheal shave surgeries can help to approximate a more feminine appearance. However, in this patients case, the photographs show that her facial structure is consistent with a female gender.  Her hairline does not show significant frontal bone prominence and her nose, chin, face and neck appear consistent with the female gender. There is a slight tracheal prominence but the photographs do not show evidence of a significantly prominent tracheal cartilage. In this case, the photographs do not show evidence of a masculine appearance of the brows, forehead, hairline, midface, and neck. These findings are relatively gender neutral and not atypical for a female. As such, this patient lacked evidence of abnormal facial structures for a female and her facial presentation is consistent within the spectrum of the female gender. Accordingly, the facial feminization surgeries (21139, 14041, 21122, 30420, 15839 and 31899) performed on 11/16/17 were not medically necessary for the treatment of this patient.
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 Upheld

Summary Reviewer 


A 47-year-old male enrollee has requested reimbursement for substance use residential treatment provided from 4/02/16 through 4/27/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  Although chemical dependency specialty services were indicated, the medical records do not demonstrate the necessity of the residential level of care following detoxification.  Upon admission, the patient had a normal mental status examination.  He was well-groomed and cooperative.  His thought process was coherent.  His mood was normal while his affect was mood-congruent and appropriate.  He denied any psychiatric history, aside from anxiety and poor sleep.  He denied suicidal ideation and expressed motivation for recovery.  The records do not demonstrate that the patient had engaged chemical dependency treatment services during the episode of illness, such as substance use counseling, anti-craving medication, sober living environments, community sponsorship, intensive outpatient programming or partial hospitalization.  This is significant because modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment.  In sum, the record does not reflect that comprehensive, evidence-based services provided in a less restrictive setting would have been inadequate at the time.  Thus, substance use residential treatment provided from 4/02/16 through 4/27/16 was not medically indicated for the treatment of this patient.  Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 62-year-old male enrollee has requested reimbursement for blood test (protein biomarker tests or 4Kscore) provided on 10/29/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for developing metastases. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The records document a prostate-specific antigen (PSA) level of 0.96 ng/mL and a palpable nodule. The patient had a negative biopsy for prostate cancer. Per the medical evidence, 4Kscore is indicated for patients with PSA levels greater than 3 ng/mL without a palpable lesion. The medical evidence does not support the services at issue in this patients case, as the records noted a palpable lesion and a PSA level which was below 3 ng/mL. Therefore, the blood test (protein biomarker tests or 4Kscore) performed on 10/29/18 was not likely to have been more efficacious than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 62-year-old male enrollee has requested reimbursement for blood test (protein biomarker tests or 4Kscore) provided on 10/29/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for developing metastases. The physician reviewer found that the 4Kscore test is a blood test which may be used to calculate an individual patients percent risk for aggressive prostate cancer on prostate biopsy. The 4Kscore test is intended to be used for patients with an abnormal prostate-specific antigen (PSA) and/or abnormal digital rectal examination who are being considered for initial or repeat prostate biopsy to identify the risk of high-grade prostate cancer. The test results provide percent risk for detecting high-grade prostate cancer on subsequent biopsy. The National Comprehensive Cancer Network guidelines recommend consideration of 4Kscore test for patients with prostate-specific antigen (PSA) levels greater than 3 ng/mL who have not yet had a biopsy. While 4Kscore may eventually have a role in reducing unnecessary biopsies, there are insufficient data on clinical outcomes to currently support routine use in screening men for prostate cancer. Hence, use of 4Kscore is not considered a clinically appropriate and generally accepted standard of care in routine screening for prostate cancer in men. The value of 4Kscore testing in men with prostate nodularity is largely unknown. In sum, the blood test (protein biomarker tests or 4Kscore) performed on 10/29/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 62-year-old male enrollee has requested reimbursement for blood test (protein biomarker tests or 4Kscore) provided on 10/29/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for developing metastases. The physician reviewer found that this patient had a negative biopsy. The 4Kscore test may be useful when there is persistent prostate-specific antigen (PSA) elevation. In this case, the records do not document persistent PSA elevation. Furthermore, 4Kscore testing may be beneficial in the prognosis of prostate cancer and its aggressiveness. The medical evidence has not demonstrated that the services at issue were likely to have been of greater benefit than standard prostate cancer screening tests in this patients case. In sum, the blood test (protein biomarker tests or 4Kscore) performed on 10/29/18 was not likely to have been more effective than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 47-year-old female enrollee has requested authorization and coverage for FreeStyle Libre continuous glucose monitor. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees diabetes. The physician reviewer found that according to the American Association of Clinical Endocrinologists and American College of Endocrinology consensus statement, real-time continuous glucose monitors should be available to all insulin-using patients regardless of diabetes type. Patients with type 2 diabetes who use antihyperglycemic agents other than insulin might also benefit from continuous glucose monitors, but the evidence base is inadequate to make a strong recommendation. The consensus statement noted the primary purpose of continuous glucose monitors is to identify glucose patterns, hypoglycemia, and hyperglycemia. Patients using personal continuous glucose monitors should use real-time data to prevent and/or treat hypoglycemia and hyperglycemic excursions, as well as retrospectively to adjust their treatment regimens. As this patient is currently using insulin, she meets these criteria. The medical evidence supports the requested device in this setting. Thus, the FreeStyle Libre continuous glucose monitor is medically necessary for the treatment of this patient. Therefore, the requested device is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 40-year-old male enrollee has requested reimbursement for acupuncture services (CPT code 97810) provided from 8/13/15 through 10/31/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees abdominal pain. The physician reviewer found the acupuncture services (CPT code 97810) provided from 8/13/15 through 10/31/15 were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of peer-reviewed medical literature supporting acupuncture as more beneficial than standard therapy. Li and colleagues reviewed the efficacy of acupuncture as a treatment for gastrointestinal (GI) dysfunction and the associated underlying mechanisms. The authors concluded that further studies are needed to investigate the effects and more systematic mechanisms in treating GI dysfunction, and to promote the application of acupuncture for the treatment of GI diseases. In addition, the documentation provided for review does not show the patients pre- and post-care condition to compare the functional gains and medication intake reduction obtained with the acupuncture performed. Accordingly, the services at issue were 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 2


A 40-year-old male enrollee has requested reimbursement for acupuncture services (CPT code 97810) provided from 8/13/15 through 10/31/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees abdominal pain. The physician reviewer found the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of objective measurable evidence of functional gain and/or improvement. There are a lack of clinical references to objective functional improvement during the dates in dispute. In sum, the records lacked sufficient evidence supporting treatment with acupuncture 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 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 40-year-old male enrollee has requested reimbursement for acupuncture services (CPT code 97810) provided from 8/13/15 through 10/31/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees abdominal pain. The physician reviewer found the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Most studies regarding acupuncture for the treatment of abdominal pain are inconclusive. Lan and colleagues stated that It remains unknown whether manual acupuncture or electroacupuncture is more effective or safer than other treatments for patients with [functional dyspepsia] FD. Given the lack of support in the peer-reviewed literature, acupuncture services (CPT code 97810) provided from 8/13/15 through 10/31/15 were 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 1

A 60-year-old female enrollee has requested authorization and coverage for 22870 and 22869 (insertion of stabilization device without compression). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient presents with chronic low back pain radiating down the left lower extremity. Functional limitations are reported in standing and walking tolerance. Clinical examination findings document positive straight leg raise, globally limited lower extremity strength, and decreased bilateral lateral leg sensation. There is imaging evidence at both L2/3 and L4/5 of mild disc bulge with mild spinal canal stenosis and no foraminal stenosis. There is imaging evidence of dextroscoliosis curvature centered at L4, which appeared to have increased since the last examination on 8/25/18. There is radiographic evidence of L4/5 anterolisthesis with no instability on flexion/extension x-rays. She has failed conservative treatment. Under consideration is a request for the Superion device at L4/5, although the requested CPT codes reflect a 2-level procedure. Current peer-reviewed literature does not fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term, peer-reviewed outcome studies to support the safety and effectiveness of this device for this patients medical condition as discussed above. There is no compelling rationale presented as to why standard surgical decompression would not be indicated. U.S. Food and Drug Administration (FDA) indications have not been met, as there is no imaging evidence of moderate spinal stenosis. There is no clear evidence that there are no FDA contraindications for the Superion procedure. There is also no documentation of dual-energy x-ray absorptiometry (DEXA) scan findings to rule out osteoporosis, given the history of daily steroid use, which would place her at high-risk. Therefore, the requested CPT codes 22869 and 22870 (insertion of stabilization device without decompression) are not likely to be more beneficial for treatment of the patients medical condition than any standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 60-year-old female enrollee has requested authorization and coverage for 22870 and 22869 (insertion of stabilization device without compression). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the interspinous process decompression offers an intermediate step in the continuum of care for patients with neurogenic intermittent claudication associated with lumbar spinal stenosis. There are many interspinous devices on the market; however, the devices lack high-quality research to demonstrate safety that is better than the current standard of care, simple decompression. Coupling surgical decompression techniques with the use of interspinous devices has added confusion to the contribution of interspinous devices in pain/symptom relief. In this case, the patient is being treated for chronic low back pain with radiation to bilateral lower extremities. There is insufficient evidence to support the use of interspinous devices for the treatment of spinal stenosis with neurogenic claudication versus decompression alone. All told, the requested CPT codes 22869 and 22870 (insertion of stabilization device without decompression) are not likely to be more beneficial for treatment of the patients medical condition than any standard therapy.