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

Summary Reviewer 2

The patient is a 45-year-old male diagnosed with amyotrophic lateral sclerosis (ALS). In October 2013 the patient presented with onset of symptoms that started about a year before. The occupational therapy evaluation performed in June 2017 indicates he is maximum assistance to total assistance for many of his activities of daily living (ADLs) including toileting, eating, and bathing. The patient is no longer ambulatory, and needs moderate to maximum assistance with transfers. The patient shows no significant respiratory compromise or bulbar symptoms. The patient has requested authorization and coverage for edaravone (Radicava). The Health Insurer has denied this request as investigational. According to the documentation submitted for review, the patient presents with late stage ALS with marked disability and sparing of respiratory and bulbar function. He initially had slow progression but has had much more rapid progression over the past year and has minimal upper limb function, and is non-ambulatory. A phase III study showed efficacy in a selective group of patients with early disease and mild-to-moderate disability (Abe, et al). However, the phase III study was designed to maximize the likelihood of a clinical response, so the criteria for entry were skewed to take those patients who were most likely to benefit, and they did benefit. Given that the patient has already been treated with riluzole and a lack of other potential therapeutic options, treatment with Radicava is likely to be beneficial for treatment of the patients ALS than any available standard therapy.  Based upon the information set forth above, the requested medication 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 Overturned

Summary Reviewer 3

The patient is a 45-year-old male diagnosed with amyotrophic lateral sclerosis (ALS) in 2013. The patient initially presented with right hand cramps and weakness. An electromyogram (EMG) showed extensive lower motor neuron changes. The patients provider recommends treatment with Radicava to slow decline of physical function, decrease caregiver burden and to improve quality of life. The patient has requested authorization and coverage for edaravone (Radicava). The Health Insurer has denied this request as investigational. Radicava is approved by the U.S. Food and Drug Administration (FDA) for the treatment of patients with ALS. Radicava has shown efficacy in a small subset of people with ALS who met criteria identified in post-hoc analysis of a previous phase III study, showing a significantly smaller decline of Revised ALS Functional Rating Scale (ALSFRS-R) score compared with placebo (Abe, et al). Based on the above, this patient is likely to benefit from the use of Radicava. All told, the request for Radicava is 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 medication 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 23-year-old male enrollee has requested authorization and coverage for orthognathic surgery. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees mandibular prognathism, maxillary hypoplasia and class II malocclusion. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. This patient has a maxillofacial skeletal deformity that cannot be corrected with orthodontics alone. The requested services are likely to result in improved musculoskeletal and dento-osseous relationships and improvement in mastication. The anterior segmental osteotomy will maximize the patients outcome. The medical evidence supports the requested services in this clinical setting. Thus, the requested orthognathic surgery is medically necessary for the treatment of this patient. Therefore, the requested services are 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
The parent of a nine-year-old transgender male enrollee has requested authorization and coverage for Supprelin LA KIT 50 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees gender dysphoria. The physician reviewer found that blocking pubertal development has rapidly become more widely available and is now part of the clinical management guidelines for adolescents in addition to cross sex hormones and surgery (at older ages) as this leads to improved psychological functioning of transgender adolescents. Per standards of care, by the Endocrine Society guidelines and World Professional Association of Transgender guidelines, puberty suppression is indicated in early puberty if desired by the minor in order to prevent irreversible physical changes including breast development in transgender males. Puberty suppression also will likely help decrease self-harm in this vulnerable population as menstruation and breast development in a transgender boy is very emotionally difficult as their body is growing more incongruent to their identity. Thus, gonadotropin-releasing hormone analogs are safe and a reversible medical intervention that should be used to relieve distress that gender dysphoric adolescents experience when their secondary sex characteristics develop. Accordingly, Supprelin LA KIT 50 mg is likely to be more effective than other available treatment options for the treatment of this patients medical condition.Based upon the information set forth above, the requested medication 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 Overturned

Summary Reviewer 2

The parent of a nine-year-old transgender male enrollee has requested authorization and coverage for Supprelin LA KIT 50 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees gender dysphoria. The physician reviewer found that there is sufficient support in the medical literature for the requested medication in this clinical setting. It is well established that patients who have gender dysphoria often suffer from psychiatric comorbidities that worsen during puberty, at which time they are at high risk of suicide. Psychiatric comorbidity such as depression, anxiety, and suicidality is common in transgender youth, two to three times more frequent than among cisgender controls. The studies indicate that there is an ideal window of opportunity for patients to receive hormonal intervention, necessitating prompt referrals, which is around sexual maturity rating 2, and not later. Several studies confirm that many of the adverse psychological outcomes noted in transgender youth may be preventable with early recognition, hormonal treatment, and mental health support. There is now strong evidence, for subjects receiving pubertal suppression followed by hormone replacement therapy during adolescence, and gender reassignment surgery in adulthood, that all have improved psychological outcomes and quality of lives compared with those not receiving this therapy. Accordingly, the studies support a benefit with initiation of pubertal blockers in this patients case.  As such, Supprelin LA KIT 50 mg is likely to be of greater benefit for treatment of this patients medical condition than the available standard methods. Based upon the information set forth above, the requested medication 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 Overturned

Summary Reviewer 3

The parent of a nine-year-old transgender male enrollee has requested authorization and coverage for Supprelin LA KIT 50 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees gender dysphoria. The physician reviewer found that based on current medical literature, it does not appear that prepubertal suppressive therapy in a pediatric patient with gender dysphoria is beneficial. Gonadotropin-releasing hormone (GnRH) agonists have been used off label for pubertal suppression in gender dysphoric children including two that are approved for the treatment of precocious puberty: leuprolide by intramuscular injection and histrelin (Supprelin LA), a subcutaneous implant with yearly dosing. However, no available medication has current U.S Food and Drug Administration approval for suppressing physiologic hormonal development in pediatric patients with gender dysphoria. The American College of Pediatricians recommend against prepubertal suppressive therapy in gender dysphoric patients. Through suppression of the hypothalamic pituitary axis, these agents prevent development of secondary sex characteristics, but also inhibit bone growth and interfere with estrogen or testosterone dependent brain maturation and inhibit fertility. In addition, suppressive therapy with histrelin may lead to irreversible changes resulting in transgender hormone therapy and/or surgery in pediatric patients who would have been expected to resolve the gender dysphoria with normal growth and development without suppressive therapy. In sum, Supprelin LA kit 50 mg is not likely to be more beneficial for the treatment of the patients gender dysphoria than any other standard therapy. 
Based upon the information set forth above, the requested medication 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: Medical Necessity
Decision: Insurer Denial Overturned

SummaryA 54-year-old female enrollee has requested authorization and coverage for spine surgeries. The Health Insurer has denied this request indicating that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. This patient presents with severe neck pain radiating into the right upper extremity with numbness, tingling and weakness. Functional limitations are documented in activities of daily living. Clinical examination findings have evidenced positive Spurlings test, motor and sensory deficits, and reflex changes consistent with imaging evidence of central canal stenosis at C5-6 (6.1 mm) and C6-7 (7.3 mm), with reported cord compression at C5-6 and C6 nerve root compromise. There was radiographic evidence of disc space narrowing at C5-6 and C6-7 with anterior spurring at C5-6 and C6-7. Evidence of a recent nonoperative treatment protocol trial and failure has been submitted. She currently presents with progressive neurologic complaints, including right hand numbness, positive Hoffmans examination, upgoing toes, broad-based gait, and hyperreflexia of the bilateral lower extremities, right greater than left. Under consideration is a request for anterior cervical discectomy and fusion at C5-6 and C6-7. Based on clinical and imaging findings, there is likely contribution to the symptomatic condition from both levels requested. There is sufficient support for the requested services in this clinical setting. Therefore, the requested spine surgeries are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


The parent of a four-year-old male enrollee has requested authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) therapy. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees autism spectrum disorder. The physician reviewer found the Health Insurer has authorized 25 hours per week of ABA services. Several studies recommend 25 or more hours of weekly ABA to ensure optimal outcomes (Roane et al; Myers et al). The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In this case, the patient demonstrates delays in social, cognitive, adaptive and executive functioning deficits and continues to demonstrate maladaptive behaviors of aggression, physical stereotypy and perseveration. In this clinical setting, 40 hours per week of ABA therapy is medically necessary for treatment of the patients medical condition. Therefore, the requested services are 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

The patient is a 54-year-old female with a family history of a sister who died from ovarian cancer, father with colon cancer, and grandmother with possible primary peritoneal cancer. The patient was noted to have a 1 cm ovarian cyst with no concerning features. Her uterus was noted to be normal. The patients evaluation included detailed genetic consultation and testing. The testing did not show any high risk mutations. As a result, the genetic counselor did not place the patient in a high risk category for gynecologic malignancies. The patient has requested authorization and coverage for hysterectomy. The Health Insurer has denied this request indicating that the requested surgery is not medically necessary. The patient has elected to undergo a prophylactic hysterectomy and bilateral salpingo-oophorectomy due to her family history. However, genetic counseling and testing do not place her in a high risk category for epithelial ovarian cancer, fallopian tube cancer or uterine cancer. Current recommendations reserve risk reducing surgery for patients in the highest risk categories with genetic mutations such as BRCA1, BRCA 2 and Lynch syndrome. Based on the patients family history and genetic testing results, she does not have a strong clinical indication for surgical cancer prophylaxis. Accordingly, the requested hysterectomy is not medically necessary for treatment of this patients medical condition.  Based on the foregoing discussion, the requested surgery is 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 34-year-old male has requested authorization and coverage for multileaf collimator device. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.The physician reviewer found in general, IMRT is not an experimental technique, but rather a radiation planning and delivery tool available to the radiation oncologist to better shape the radiation dose distribution, and therefore minimize the dose to normal structures. IMRT is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure.  There are emerging data for the use of IMRT for Hodgkins lymphoma. The rationale to use IMRT includes relative sparing of the lungs, heart, salivary glands, and other tissues. In select patients, IMRT may significantly reduce the dose to these structures.  However, 77338 is billed for the treatment planning and not the treatment delivery, and it is billed once per plan.  Thus, the superior efficacy of the requested 45 units of 77338 has not been established.  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.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2


A 34-year-old male has requested authorization and coverage for multileaf collimator device. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the services at issue in this patients case.  CPT code 77338 should only be billed once per IMRT plan, not once per beam nor once per delivery. As such, there should only be a single billing of CPT code 77338 for each time CPT code 77301 (for IMRT planning) is billed.  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.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3


A 34-year-old male has requested authorization and coverage for multileaf collimator device. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found per the submitted records, the Health Insurer has approved coverage for IMRT. However, the requested 77338 x 45 is not considered to be more beneficial than standard therapy. Per coding guidelines, 77338 represents the multileaf collimator device for intensity IMRT, design and construction per IMRT plan.  This code is to be billed only once per plan, regardless of the number of ports constructed for the plan. Therefore, superior efficacy of the requested services has not been established.  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.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 45-year-old female enrollee has requested reimbursement for Privigen (intravenous immune globulin or IVIG) from 10/10/16 through 4/10/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees relapsing remitting multiple sclerosis. The physician reviewer found that the documentation provided does not support the medical necessity of the services at issue in this clinical setting. The patient has been diagnosed with relapsing remitting multiple sclerosis. While she has tried two interferons, Copaxone and Tecfidera, for primary disease modification, there are currently numerous other medications that are available for the treatment of relapsing remitting multiple sclerosis which this patient has not tried. The patient has the option of considering other medications such as Tecfidera, Tysabri, and Zinbryta prior to considering the use of Privigen. Moreover, Privigen is not U.S. Food and Drug Administration approved disease modifying agent for the treatment for RRMS. Therefore, for the reasons stated above, Privigen (intravenous immune globulin or IVIG) is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 70-year-old female enrollee has requested reimbursement for radiofrequency ablation of the right side performed on 5/25/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees varicose veins. The physician reviewer found the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  There is a lack of documentation of a concerted effort to treat conservatively.  It is noted that the anatomy of the accessory vein was likely not amenable to endovenous ablation.  There is no evidence the patient was having activity limiting symptoms despite the use of compression stockings.  In sum, radiofrequency ablation of the right side performed on 5/25/16 was not likely to be more efficacious than other treatment options.  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 2


A 70-year-old female enrollee has requested reimbursement for radiofrequency ablation of the right side performed on 5/25/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees varicose veins. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  This patient has C2 disease with symptoms and anterior accessory saphenous vein reflux. Standard of care supports treatment in this patients case.  Generally, the indications for treatment include pain or other discomfort, edema, varix hemorrhage, recurrent superficial phlebitis, stasis dermatitis, or ulceration.  The medical evidence supports treatment of patients with C2 disease.  Per the current evidence, radiofrequency ablation of the right side performed on 5/25/16 was likely to have been more efficacious than other treatment options.  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 3


A 70-year-old female enrollee has requested reimbursement for radiofrequency ablation of the right side performed on 5/25/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees varicose veins.The physician reviewer found the medical evidence supports the services at issue in this patients case.  The medical literature suggests that treatment of the anterior accessory vein can lead to favorable hemodynamic changes in the treatment of venous insufficiency.  Providers may use endovascular techniques to treat an anterior accessory saphenous vein if it is straight enough to accept a treatment catheter. There are also providers who use Varithena for these procedures because the foam is able to travel in the branch if it is tortuous. The literature supports the use of ablation for treatment of the refluxing anterior accessory saphenous vein.  Thus, radiofrequency ablation of the right side performed on 5/25/16 was likely to have been of greater benefit than other treatment methods.  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.