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

Summary Reviewer 

The patient is an 18-year-old female who presented to her provider on 11/06/20. Per the records, she had fallen from a horse in November 2020 with resultant left shoulder pain. The patient has requested reimbursement for MRI performed on 11/12/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the American College of Radiology (ACR) has established appropriateness criteria for various clinical presentations and disorders, in order to better guide clinicians on the most efficacious and efficient use of imaging. As a first imaging modality, plain films are recommended. However, when plain films are negative, the next imaging test recommended is an unenhanced MRI of the shoulder. As noted by the ACR, MRI Shoulder Non-contrast MRI is a reasonable imaging study in the setting of acute nonlocalized traumatic shoulder pain and noncontributory radiographs. In the acute trauma setting, noncontrast MRI may be preferred to magnetic resonance (MR) arthrography, as acute intra-articular pathology will typically produce significant joint effusion for assessment of intra-articular soft-tissue structures. MRI is the preferred imaging modality in assessing extra-articular soft-tissue traumatic pathology such as capsular and ligament tears. MRI is also sensitive for diagnosing bone marrow contusion and has been shown to be beneficial in assessing shoulder physeal injuries in pediatric patients. In general, it is a widespread clinical practice to follow plain x-rays with an MRI, especially in a young patient with an immediate traumatic event. Significant issues, such as a labral tear or rotator cuff tear, can be best imaged with MRI. Despite physical therapy, these types of lesions generally do not heal themselves. Therefore, MRI performed on 11/12/20 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The parent of a 16-year-old transgender male enrollee has requested authorization and coverage for bilateral mastectomy. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found that from the provided materials, it does not appear that appropriate or healthy transition of a psychosocial nature has occurred for the patient. Since the guidelines for surgery in adolescence are not concrete and are subject to further subjective analysis, the decision-making needs to be based on overall psychosocial adjustment. There is a lack of objective evidence in this case to recommend, with any degree of certainty, that the patient has the capacity to consent to this procedure at this time. World Professional Association for Transgender Health (WPATH) indicates that bilateral mastectomy may be appropriate when the patient has lived for ample time as the desired gender, with hormone therapy and psychosocial adjustment to the desired gender. WPATH indicates that psychotherapy should focus on reducing a childs or adolescents distress related to the gender dysphoria and on ameliorating any other psychosocial difficulties. In this case, there is no evidence that psychosocial therapy has occurred.  There are no therapy records in the supplied materials.  There is no clinical assessment of adjustment issues, whether negative or positive, by a behavioral health clinician in the form of clinical records. Thus, the requested bilateral mastectomy is not medically necessary for the treatment of this patient. Therefore, the requested procedure 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 21-year-old female enrollee has requested reimbursement for greater occipital nerve injection provided on 11/21/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees occipital neuralgia. The physician reviewer found that the records document a diagnosis of bilateral greater occipital neuralgia. Based on a review of the medical record, the patients conditions may be exacerbated as a result of the occipital neuralgia. The use of nerve blocks for the treatment of occipital neuralgia is well-established and is known to be an effective method of treatment for this condition. Furthermore, the treatment of this condition may result in improvement of the patients chronic migraines, as occipital neuralgia is known to be secondary cause for exacerbation of migraines. Therefore, greater occipital nerve injection on 11/21/17 was likely to have been more effective 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 2

A 21-year-old female enrollee has requested reimbursement for greater occipital nerve injection provided on 11/21/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees occipital neuralgia. The physician reviewer found that neuralgia is a type of neuropathic pain. Occipital neuralgia specifically refers to pain or headache in the occipital region in the greater, lesser, or third occipital nerve areas which can also be accompanied by dysesthesia or decreased sensation in the nerve distribution. Per the submitted documentation, this patient had evidence of occipital neuralgia on examination. The treatment of choice for occipital neuralgia is a local occipital nerve block due to its ability to relieve pain as well as act as a diagnostic marker. According to the current data, greater occipital nerve injection on 11/21/17 was likely to have been superior over 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 21-year-old female enrollee has requested reimbursement for greater occipital nerve injection provided on 11/21/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees occipital neuralgia. The physician reviewer found that Occipital nerve blocks are not supported for the treatment of migraine or other type headaches.  The blocks are supported for diagnostic purposes, but are not supported for therapeutic treatment. There is a lack of long-term benefit supported by peer-reviewed literature.  Dilli and colleagues noted that greater occipital nerve blocks did not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. Thus, greater occipital nerve injection on 11/21/17 was not likely to have been more effective than other available 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 Upheld

Summary Reviewer 1

A 67-year-old female enrollee has requested reimbursement for the intraoperative radiation therapy performed on 7/19/16. The Health Plan has denied this request indicating that the service at issue is considered investigational for treatment of the enrollee breast cancer. The physician reviewer found that there is a lack of medical literature supporting the service at issue in this clinical setting. Silverstein and colleagues studied intraoperative radiotherapy for early-stage breast cancer. The study revealed that intraoperative radiotherapy was associated with a nine-fold increase in ipsilateral breast recurrence, although five-year overall survival was similar. In addition, the American Society for Radiation Oncology (ASTRO) consensus guidelines recommended intraoperative radiation therapy for those with suitable criteria with invasive cancer, and not for patients with DCIS. Moreover, treatment with intraoperative radiation therapy is not the standard therapy for breast cancer. Given the lack of support in the peer-reviewed literature, the intraoperative radiation therapy performed on 7/19/16 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the service at issue was 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 67-year-old female enrollee has requested reimbursement for the intraoperative radiation therapy performed on 7/19/16. The Health Plan has denied this request indicating that the service at issue is considered investigational for treatment of the enrollee breast cancer. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines endorse the use of intraoperative radiation therapy in the treatment of breast cancer. The patient meets all of the suitable criteria for the use of intraoperative radiation in patients with DCIS. Furthermore, intraoperative radiation would decrease toxicities from the patient undergoing radiation a second time to an adjacent field. Therefore, the intraoperative radiation therapy performed on 7/19/16 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 service at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3
A 67-year-old female enrollee has requested reimbursement for the intraoperative radiation therapy performed on 7/19/16. The Health Plan has denied this request indicating that the service at issue is considered investigational for treatment of the enrollee breast cancer. The physician reviewer found that the IORT performed on 7/19/16 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The American Society for Radiation Oncology (ASTRO) consensus guidelines for accelerated partial breast irradiation recommend low-energy x-ray IORT be used within the context of a prospective registry or clinical trial. ASTRO guidelines further state that when IORT is used it should be restricted to women with invasive cancer considered suitable for partial breast irradiation. In this case, based on the clinical documentation provided for review the patient is not considered suitable candidate given she has pure DCIS. Thus, IORT is not clinically indicated for this patient. For the reasons provided, the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 26-year-old female enrollee has requested reimbursement for DecisionDx testing performed on 4/28/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that per National Comprehensive Cancer Network (NCCN) guidelines, adjuvant immunotherapy is indicated for stage III disease and is not governed by results of molecular profiling. Further, there is a paucity of randomized prospective controlled trials demonstrating the results from DecisionDx have improved treatment decisions and outcomes. Accordingly, the DecisionDx testing performed on 4/28/17 was 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

A 26-year-old female enrollee has requested reimbursement for DecisionDx testing performed on 4/28/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion. Metastases to regional lymph nodes may be amenable to excision but suggest an increased risk for the development of metastatic disease in the future (Balch, et al). The data on the DecisionDx test for melanoma does not support its routine use after sentinel lymph node biopsy. According to the National Comprehensive Cancer Network (NCCN), there has been a lack of consistency with various genes being used as biomarkers in this clinical setting. Thus, the DecisionDx testing performed on 4/28/17 was 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

A 26-year-old female enrollee has requested reimbursement for DecisionDx testing performed on 4/28/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the DecisionDx-Melanoma test is an attempt to determine risk of recurrence for early stage melanoma. However, the treatment protocol for follow up of melanoma patients is summarized in the National Comprehensive Cancer Network (NCCN) guidelines. These guidelines note there is a lack of data to support using adjuvant therapy based on DecisionDx testing results. The follow up of melanoma patients is not tailored to each patient risk of recurrence, but rather is global to all patients with melanoma. Given these findings, the DecisionDx testing performed on 4/28/17 was 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 44-year-old male with a history of hypothyroidism that is complicated by weight gain and hypercholesterolemia.  The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that hypothyroidism is a common condition of thyroid hormone deficiency, which is readily diagnosed and managed but potentially fatal in severe cases if untreated. Synthetic thyroid hormone (levothyroxine) is the standard of care for patients with hyperthyroidism. Thyroid ultrasonography has established itself as a popular and useful tool in the evaluation and management of thyroid disorders. Indications for thyroid ultrasound include confirmation of the presence of a thyroid nodule, differentiation between benign and malignant masses, to assess for the presence of postoperative residual or tumor, to screen for patients at high risk for thyroid malignancy, and to provide information to help guide interventional procedures, such as a fine-needle aspiration biopsy. There is currently, however, no indication for routine thyroid ultrasound for patients with history of hypothyroidism alone. Therefore, 76536 (ultrasound, soft tissues of head and neck, real time image) performed on 1/27/21 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The parent of a 17-year-old male enrollee has requested authorization and coverage for nursing care in the home (S9124). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient sustained significant disability as a result of anti-NMDA-receptor encephalitis with subsequent encephalopathy. As a result of this ongoing disability, he has a number of skilled nursing needs as described above. These are not custodial needs. He requires constant monitoring for seizure necessitating rescue medication, respiratory distress necessitating application of supplemental oxygen, and gastrostomy care. Without the expertise of skilled nursing, he may experience further disability and compromise. Therefore, the requested nursing care in the home (S9124) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 69-year-old female enrollee has requested reimbursement for air ambulance services provided on 6/18/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that Shirley Ryan Ability Lab is a state of the art inpatient rehabilitation campus determined to be the best option for this patient. On 6/15/18, a request for urgent pre-authorization for medically configured fixed-wing air transport was sent to the Health Insurer. On 6/18/18, the patient was transferred by medically configured fixed-wing aircraft to the receiving inpatient rehabilitation center. On 6/19/18, four days after the request for urgent pre-authorization, the Health Insurer authored a denial letter for the services in question. As detailed in the air ambulance records, the patient at the time of transport was described as alert but nonverbal, and she did not follow commands. The records noted left-sided weakness. She was not a candidate for commercial air travel. The receiving facility was greater than 303 miles away with a reported five-hour ground transport time; well outside generally accepted time limits for this type of patient. In sum, the Shirley Ryan Ability Lab was determined to be the best option for this patient, and she was not a candidate for ground transport or commercial air travel. Therefore, air ambulance services provided on 6/18/18 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 60-year-old female who has a long history of migraines and facial pain. The patient has requested authorization and coverage for cervical spine MRI. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that headaches are a common clinical presentation and often present the patient and the medical practitioner with an issue of when to obtain imaging. Multiple organizations have tried to address this dilemma and have published guidelines. The American College of Radiology has published aAppropriateness Criteriaa for various clinical presentations in order to help guide the practitioner in the most efficacious use of imaging. One of these guidelines is titled aHeadachea, and it is divided into various clinical presentations. The one most closely applicable to this patient is Variant 6, aChronic headache. No new features. No neurologic deficit. Initial imaging.a In this variant, imaging is not recommended. Specifically, MRI is felt to be ausually not appropriatea. Evans and colleagues noted, aIt is not necessary to do neuroimaging in patients with headaches consistent with migraine who have a normal neurologic examination.a Holle and colleagues noted, 
aUsually, neuroimaging is not required in patients with episodic migraine who present with typical headache features according to the classification of the International Headache Society (IHS)aand normal neurologic examination. A meta-analysis of studies with migraine patients showed that in cases with normal neurologic examination and a typical clinical presentation significant brain pathology was only detected in 0.18% of the patients. Therefore, neuroimaging is usually unnecessary in these patients.a There is a lack of support for the requested services in this clinical setting. Therefore, the requested cervical spine MRI is not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The parent of a 15-year-old enrollee has requested reimbursement for adolescent mental health residential treatment provided from 6/02/18 through 8/04/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in terms of risk of harm, the records support a score of 2. The medical records indicate that the patient was not actively suicidal. He did not engage in any self-harm behaviors but did have a reported history of suicidal ideation. With regards to functional status, the records support a score of 3. The patient has had issues with level of functioning due to mental illness in the past and relationship problems, but overall showed appropriate daily functioning while in treatment, including cooperation in treatment and intact activities of daily living. In terms of comorbidity, the records support a score of 1. The patient did not have active medical problems or substance use that affected his primary psychiatric issues. With regards to level of stress of the recovery environment, the records support a score of 2. There is no indication of an unsafe home environment. In terms of level of support of the recovery environment, the records support a score of 2. The patients family was actively involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 3. It appears that the patient was stable while in the residential treatment center. In terms of acceptance and engagement of the child, the records support a score of 2. The patient actively participated in therapy. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Therefore, the patient has a composite score of 17. This score correlates with intensive outpatient services. Therefore, adolescent mental health residential treatment provided from 6/02/18 through 8/04/18 was not medically necessary for the treatment of this patient.