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

Summary Reviewer 


A 49-year-old female enrollee has requested reimbursement for DecisionDX-Melanoma assay test performed on 6/30/14. The Health Insurer has denied this request indicating that the test at issue was not medically necessary for evaluation of the enrollees cutaneous melanoma. The physician reviewer found the prognosis of cutaneous melanoma has classically been determined by the staging system as documented by Balch and colleagues. Mitotic index has also been thought to add a bit more to the prognostics. By these determinations, this patient has an excellent prognosis. DecisionDX is a study of 31 genes in the melanoma cells. It then classifies that melanoma as either high or low risk for recurrence (Dillion et al). The National Comprehensive Cancer Network (NCCN) guidelines state there is interest in these newer genetic profiles, but only in the context of a clinical trial. Currently, medical studies are not clear as to how DecisionDX data compares to the 10 year data of the Balch determinations and whether it is useful in clinical practice for patients with a good prognosis, as is true in this patients case. In sum, this assay was not medically necessary in evaluating this patients likelihood of metastasis in cutaneous melanoma. Based on the information above, the test at issue was 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 


A 44-year-old female enrollee has requested reimbursement for AlloMap testing performed on 9/10/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollee, who is status post cardiac transplant.  The physician reviewer found this patient underwent cardiac transplantation on 6/19/13 followed by AlloMap gene expression profile testing on 9/10/14 to help assess for rejection.  In this circumstance, while endomyocardial biopsies have been the accepted standard for assessing rejection in patients with cardiac transplantation, gene expression profiling testing has shown promise in recent years.  Per the medical evidence, a strategy using AlloMap testing is an appropriate alternative to routine endomyocardial biopsies in stable patients at low risk for rejection who are six months to five years after cardiac transplantation.  This patient fits all of those criteria, and there is also documentation to support that the AlloMap test in question was performed in place of an endomyocardial biopsy rather than in addition to an endomyocardial biopsy.  All told, AlloMap testing performed on 9/10/14 was medically indicated for the evaluation of this patient.  Therefore, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 63-year-old male enrollee has requested reimbursement for CPT 64999 (unlisted procedure, nervous system, right wrist anterior and posterior interosseous neurectomy) performed on 6/10/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that this patient presented with chronic right wrist pain that interfered with his activities of daily living. He had a past medical history that included right distal radius fracture. Clinical examination findings were consistent with imaging evidence of right wrist post-traumatic arthritis of the radioscaphoid joint and STT joint with positive ulnar variance of 7.5 mm. He had failed to achieve sustained improvement with activity modification, medications, bracing and steroid injection. He underwent right wrist anterior and posterior interosseous neurectomies on 6/10/19 as an alternative to motion-limiting surgeries, including wrist fusion, proximal row carpectomy, and radioscapholunate arthrodesis. Current evidence-based medical literature supports the use of anterior and/or posterior interosseous neurectomies for the treatment of chronic wrist pain and to delay or avoid wrist fusion/reconstruction surgeries. There is adequate literature support for the use of this procedure as salvage prior to fusion. He had failed reasonable and/or comprehensive conservative treatment, and no additional conservative treatment would have been reasonably expected to improve his medical condition. Therefore, CPT code 64999 (unlisted procedure, nervous system, right wrist anterior and posterior interosseous neurectomy) performed on 6/10/19 was likely to have been more beneficial for treatment of the patientas medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 63-year-old male enrollee has requested reimbursement for CPT 64999 (unlisted procedure, nervous system, right wrist anterior and posterior interosseous neurectomy) performed on 6/10/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that this patient had significant right osteoarthritis following wrist fracture 20 years ago. A review of the medical literature shows that the requested procedure does have a moderate amount of good quality literature to support efficacy in patients who are otherwise only candidates for wrist fusion surgery. The submitted records do demonstrate that the patient has failed an appropriate course of conservative management. There is sufficient support for the services at issue in this clinical setting. Therefore, CPT code 64999 (unlisted procedure, nervous system, right wrist anterior and posterior interosseous neurectomy) performed on 6/10/19 was likely to have been more beneficial for treatment of the patientas medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 63-year-old male enrollee has requested reimbursement for CPT 64999 (unlisted procedure, nervous system, right wrist anterior and posterior interosseous neurectomy) performed on 6/10/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that this patient has a history of severe post-traumatic arthritis of the right wrist 20 years post fracture. Anterior interosseous neurectomy and posterior interosseous neurectomies are wrist denervation surgical procedures which are well-documented to relieve wrist pain due to arthritis, as in this case. Partial wrist denervation is a useful palliative procedure for chronic wrist pain when other surgical procedures are not possible or desirable. Per the medical literature, this procedure can be performed through small incisions and is known to provide pain relief in this setting. Thus, CPT code 64999 (unlisted procedure, nervous system, right wrist anterior and posterior interosseous neurectomy) performed on 6/10/19 was likely to have been more beneficial for treatment of the patientas medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 19-year-old female with anorexia nervosa, post-traumatic stress disorder, major depressive disorder, and generalized anxiety disorder. She was admitted to a residential treatment center on 12/23/19. The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is a beneficial tool in determining the appropriate level of care. With regards to risk of harm, the records support a score of 4. The records noted a past history of multiple suicide attempts, and she expressed suicidal ideation at the residential treatment center. In terms of functional status, the records support a score of 3. The records noted 
moderate impairment due to troubled relationships with parents and lack of employment or school attendance prior to admission. With regard to comorbidity, the records support a score of 3 due to the physical manifestations of anorexia nervosa, including low weight and laboratory abnormalities, co-occurring with post-traumatic stress disorder, depression, and anxiety symptoms. In terms of level of stress of the recovery environment, the records support a score of 3 due to discord with parents and recent transition back to the United States after a year of living abroad. With regard to level of support of the recovery environment, the records support a score of 3 due to parents ambivalence toward participating in treatment and lack of recent contact with the patient. In terms of treatment and recovery history, the records support a score of 4 due to the persistence of symptoms despite prior extensive treatment. With regard to engagement and recovery status, the records support a score of 3 due to poor insight and limited judgment. Thus, the patient has a composite score of 23. In this case, the records support medically monitored residential services. Therefore, eating disorder residential treatment center services from 1/23/20 forward were and are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 63-year-old male enrollee has requested authorization and coverage for surgical insertion of an interspinous process spacer. 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 a 20-year history of chronic low back pain. Signs/symptoms are consistent with lumbar spinal stenosis with neurogenic claudication. Clinical examination findings did not evidence a focal neurologic deficit. There is imaging evidence presented from 2016 that showed no significant central canal stenosis and mild bilateral neural foraminal stenosis at L4/5. There is severe degenerative disc disease noted at the L5/S1 level. There is radiographic evidence from 2016 that documented a mild levoscoliosis with apex at L3/4 and anterolisthesis at L4/5 that reduced 2 mm in extension. He has reportedly failed conservative treatment, including activity modification, medications, and lumbar epidural steroid injections. Current evidence-based medical guidelines and peer-reviewed literature do 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 use of this device for this patients medical condition. Additionally, U.S. Food and Drug Administration (FDA) criteria have not been fully met. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients for whom operative treatment is indicated at no more than two levels from L1 to L5 for a diagnosis of moderate degenerative lumbar spinal stenosis. There is no imaging evidence of moderate spinal stenosis at the L4/5 level on the submitted magnetic resonance imaging (MRI) report. This patients body mass index is documented as 41.28, which is an FDA contraindication. There is no recent documentation of scoliosis films evidencing a Cobb angle of less than 10 degrees, or flexion/extension films showing no progression of the dynamic grade 1 spondylolisthesis noted previously at the L4/5 level, both of which are FDA contraindications. Therefore, the requested surgical insertion of an interspinous process spacer is not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 63-year-old male enrollee has requested authorization and coverage for surgical insertion of an interspinous process spacer. 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 interspinous spacers were developed to avoid the risks of a traditional laminectomy via a less invasive technique that is reversible. The device is placed percutaneously in the interspinous space with minimal disruption of the spinal anatomy. The goal is to limit extension of the spine, minimizing the effects of spinal degeneration and enlarging the spinal canal and neural foramina area. This patient is being treated for lumbar spinal stenosis with neurogenic claudication. While there are many interspinous devices on the market, none have high quality research to demonstrate superiority over the current standard of care, simple decompression. The use of an interspinous spacer for spinal stenosis as a minimally invasive, stand-alone procedure has shown high failure and complication rates.  Until data exists that demonstrate noninferiority of these devices to the current gold standard treatment, simple decompression, the use of the requested device as a standalone procedure should be considered investigational for the treatment of the patients condition. In sum, the requested surgical insertion of an interspinous process spacer is not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 63-year-old male enrollee has requested authorization and coverage for surgical insertion of an interspinous process spacer. 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 had a long history of neurogenic claudication. He has failed conservative treatment for over six months, including nonsteroidal anti-inflammatory drugs, opioids, physical therapy, epidural steroid injections, and bracing. His provider has recommended minimally invasive interspinous process spacer using the Superion device. Nunley and colleagues presented a four-year follow-up of 89 patients who underwent the procedure for spinal stenosis. At four years after the procedure, 75 of 89 patients with Superion (84.3%) demonstrated clinical success in terms of back and leg pain. The minimally invasive implantation procedure of the Superion device provided relief of symptoms of intermittent neurogenic claudication in these patients with moderate lumbar spinal stenosis. The second article referenced is a five-year follow-up and indicated that 75 percent of these patients continued to do well and did not require any other treatment such as an open decompression/fusion procedure. Thus, the requested surgical insertion of an interspinous process spacer is likely to be more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 42-year-old female enrollee has requested reimbursement for mental health inpatient services provided from 5/11/15 through 5/14/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees bipolar disorder type 1.  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. Although community intervention settings optimize treatment gains, episodic placement in more restrictive settings is often clinically appropriate for those with serious mental illness. The records indicate that this patient was plagued with the most serious of affective disorders. Bipolar disorder with psychotic features is commonly associated with poor clinical outcomes. When considering the formidable symptom complex, multiple recent hospitalizations, available support system and functional impairment across multiple domains, a conservative inpatient hospitalization was to be expected. During the course of the admission, the patient was hostile, unpredictable and agitated. She had difficulty self-regulating her behaviors and poor insight to her illness. She had refused mood stabilizing medication. On 5/6/15, she was administered psychotropic medication via injection due to her agitation. On 5/11/15, the patient was assessed to lack medical decision making capacity. Thereafter, she was adherent with pharmacotherapy. On 5/12/15, the patients hostility had tempered to irritability while she remained circumstantial, paranoid and grandiose. However, the patient evidenced a positive response to pharmacologic intervention. She was guarded, but better organized and able to participate in discharge planning. Although not suicidal, the patients condition was consistent with grave disability. Based on her illness burden and history of multiple psychiatric admissions in less than one year, the mental health inpatient services provided from 5/11/15 through 5/14/15 were reasonably expected to improve her condition and prevent a more serious episode of illness and thus were medically necessary. Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 58-year-old male enrollee has requested authorization and coverage for Vesicare. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees nocturia. The physician reviewer found that based on the medical literature and the clinical records submitted for review, the request for Vesicare is medically necessary for treatment of the patients medical condition. In this case, the patient presents with urinary obstruction as well as overactive bladder. Treatment with Vesicare is medically indicated to relieve the patients overactive bladder symptoms. In addition, the patient reports significant improvement with Vesicare. For the reasons provided, the request for Vesicare has been established as medically necessary for treatment of the patients medical condition. Therefore, 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 61-year-old female enrollee has requested reimbursement for mental health inpatient treatment provided from 9/03/14 through 10/15/14.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found the patients affective illness and anxiety burden was complicated by a poorly defined self-concept and treatment non-adherence, the confluence of which contributed to, if not fueled, a recurrent symptom complex.  Per the medical records, the patient was not experiencing an acute psychiatric syndrome.  She was not suicidal, homicidal, psychotic or gravely disabled.  She was able to independently complete activities of daily living.  The record did not demonstrate that the patient had failed a less restrictive treatment setting, such as partial hospitalization or an intensive outpatient program or even consistent outpatient services, during the episode of illness.  Modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment.  However, there was no evidence to suggest that a less restrictive treatment setting would have been insufficient.  Thus, mental health inpatient treatment provided from 9/03/14 through 10/15/14 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 54-year-old male enrollee has requested reimbursement for substance use inpatient detoxification/residential services provided from 10/19/15 through 11/20/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the documentation does not support the medical necessity for the services at issue. There were no emotional, behavioral, or cognitive symptoms to warrant residential level of care from 10/19/15 through 11/20/15. The patient was not in withdrawals. He showed no suicidality or homicidality.  He was medically and psychiatrically stable.  He had not used opioids for at least nine months prior to admission. Cocaine use disorder does not require inpatient treatment.  The records did not indicate that he was not placed on any new medications.  There was no evidence of a high degree of impulsivity, aggression, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He was accepting the principles of treatment, had a strong background of 20 years of sobriety with a history of very active involvement in AA as a member, sponsor, and speaker.  Given this, he would have had some insight into the disease process of addiction.  He learned and implemented skills and worked on a relapse prevention plan.  He did not require the 24 hours a day, 7 days a week environment of residential. He could have been treated in intensive outpatient program. As such, substance use inpatient detoxification/residential services provided from 10/19/15 through 11/20/15 were not medically necessary for 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 41-year-old male enrollee has requested reimbursement for Decision DX Melanoma Assay performed on 12/16/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  Decision DX Melanoma Assay has been developed for patients with stage I and II cutaneous melanoma.  However, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy.  Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate benign from malignant neoplasms, or melanomas at low versus high risk for metastasis, routine (baseline) genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study.  All told, Decision DX Melanoma Assay performed on 12/16/15 was not likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were 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.