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

Summary Reviewer

The patient is a 47-year-old male with Crohns disease. Per the providers note dated 3/15/18, the patient was diagnosed in 2000 and has failed prednisone, Entocort, Cipro, Flagyl, Xifaxan, Pentasa, 6-mercaptopurine, methotrexate, and Remicade. He has had a temporary ileostomy, bowel resection, ileocecectomy in 2000, and takedown surgery. The patient started Humira every 14 days and then every seven days in 2005, which healed his anal fistulas. He was on Humira 80 mg every seven days since mid-January 2018 but was later switched back to Humira 40 mg every seven days with concurrent methotrexate and Entocort. A colonoscopy on 3/2/18 showed recurrence at the anastomosis and neo-terminal ileum. The note states that the patients Humira level was 26 with negative anti-Humira antibody testing, and that Stelara infusion was given on 3/13/18. The patient was having mild intermittent bleeding but no abdominal pain. The patient has requested authorization and coverage for Humira injections 80 mg every seven days. The Health Insurer has denied this request indicating that the requested medication dosage is not medically necessary. The use of Humira 40 mg more frequently than every 14 days is supported in the medical literature to prevent disease complications. In the CHARM trial, which was a high-quality phase III randomized double-blind placebo-controlled 56-week study, 27% of open-label patients required dose escalation with weekly dosing (Colombel, et al). The remission rate with weekly dosing was reported at 46.9% versus 22.5% when dosing every other week (Sandborn, et al). The use of Humira more frequently than every 14 days is supported by current medical literature, and preferred to changes to a different therapy, which may result in loss of disease control (Van Assche, et al). The consequences of uncontrolled disease can include disease flare, inflammation related sequelae such as the development of a fistula, stricture, or abscess, and the need for hospitalization or surgery. The records indicate that this patient failed Humira 40 mg dosed every seven days, and had improvement with Humira 80 mg dosed every seven days. For these reasons, the request for Humira 80 mg every seven days is supported as medically necessary for the treatment of the patients Crohns disease.  Based on the foregoing discussion, the requested medication dosage 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 31-year-old male enrollee has requested reimbursement for mental health intensive outpatient treatment provided from 8/02/18 through 9/04/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that in cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation or past suicide attempts. With regards to functional status, the records support a score of 1 due to apparent transient impairment in functioning. His activities of daily living were intact. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to the existence of medical problems which were not immediately threatening and had no impact on the course of his present illness. With regards to level of stress of the recovery environment, the records support a score of 1. His living environment posed no significant threats or risks. In terms of level of support of the recovery environment, the records support a score of 2. Some elements of his support system were willing and able to participate in treatment, if requested, as referenced by including his family in treatment. With regards to treatment and recovery history, the records support a score of 2. The patients substance sobriety has been managed for moderate periods of time. In terms of engagement and recovery status, the records support a score of 2 due to good cooperation in treatment with his current provider. Therefore, the patient has a composite score of 11. This score correlates with clinic-based services without frequent contact. Thus, the patient could have safely been treated in a less restrictive setting. Therefore, mental health intensive outpatient treatment provided from 8/02/18 through 9/04/18 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 63-year-old male who was found to have an elevated prostate-specific antigen (PSA) level. He was referred for magnetic resonance imaging (MRI) of the prostate gland, which was performed on 4/13/19. The physician reviewer found that currently, the diagnostic pathway for prostate cancer detection is often initiated by PSA level testing and digital rectal examination. This is often followed by transrectal ultrasound guided biopsy (TRUS). However, anterior tumors within the prostate are often missed by TRUS. Further, TRUS biopsy has historically underestimated the final Gleason grading, leading to inaccurate risk stratification and selection of therapeutic options. Magnetic resonance imaging has been used for noninvasive assessment of the prostate gland since the 1980s. Initially, prostate MRI was based solely on morphologic assessment using T1-weighted and T2-weighted pulse sequences, and its role was primarily for locoregional staging in patients with biopsy proven cancer. However, it provided limited capability to distinguish between pathologic tissue and clinically insignificant prostate cancer from significant cancer. Advances in technology, however, have dramatically changed MRI imaging for prostate cancer. The center that had performed this patients MRI refers to this advanced technology as three-dimensional rendering. In fact, three-dimensional rendering is an older term to describe what is widely described as multiparametric MRI. By using
these newer techniques, which are widely accepted, one is able to obtain three-dimensional volumetric images. By obtaining images from the whole area within the body, there is a higher signal-to-noise ratio, making the images sharper and more accurate in detecting lesions. This technique also allows fusing the MRI to ultrasound and to guide TRUS. The medical evidence supports the services at issue in this clinical setting. As stated by Girometti and colleagues, Multiparametric magnetic resonance imaging is the standard of care for assessing prostate cancer. Therefore, three-dimensional rendering with interpretation and reporting of magnetic resonance imaging performed on 4/13/19 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 65-year-old female enrollee has requested reimbursement for collagen crosslink testing and homocysteine testing provided on 12/03/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that osteoporosis is a condition of thinning of the bones that leads to increased risk of fracture. It is defined by the World Health Organization as a bone mineral density of 2.5 standard deviations or more below the mean peak bone mass as measured by dual-energy x-ray absorptiometry (DEXA).  Bone mineral density (BMD) assessment, via DEXA, is still the criterion standard for evaluation and diagnosis of osteoporosis. However, because changes in bone mass and density in response to antiresorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover may be a useful adjunct in monitoring of osteoporotic patients treated with antiresorptive agents. Evidence suggests that biochemical markers could be useful in making therapeutic decisions because, in general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine. The medical evidence supports collagen crosslink testing in this clinical setting. However, there is a lack of support for homocysteine testing in this patients case. Ohishi and colleagues found that serum total homocysteine levels had no correlation with bone mineral density. While some studies have suggested that there may be an association between homocysteine levels and bone loss, to date, the association between homocysteine imbalance and its role in bone loss remains unclear. Enneman and colleagues noted plasma levels of homocysteine were significantly inversely associated with both bone ultrasound parameters and with bone mineral density. However, the size of the associations seems to be of limited clinical relevance and may, therefore, not explain the previously observed association between plasma homocysteine and osteoporotic fracture incidence. In sum, collagen crosslink testing provided on 12/03/18 was likely to have been more beneficial than other available methods of evaluating this patient. However, the superior effectiveness of homocysteine testing has not been established.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 65-year-old female enrollee has requested reimbursement for collagen crosslink testing and homocysteine testing provided on 12/03/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient has been diagnosed with osteoporosis. She has received treatment with Forteo, followed by Tymlos. As part of management, her endocrinologist has ordered collagen crosslink testing and homocysteine testing. The use of markers of bone turnover is standard practice among endocrinologists and other specialists in osteoporosis and is a tool to monitor therapy. Collagen crosslinks are bone turnover markers that are used as a guide to monitor compliance and efficacy of treatment. They also help to identify non-responders that require additional work-up for other causes of osteoporosis. The medical evidence indicates that the principal clinical utility of bone turnover markers is for monitoring therapy. In this case, the patients provider is using the information from this test result to help establish whether the patient has responded to therapy and determine follow-up therapy after anabolic treatment with Tymlos and Forteo. Regarding homocysteine, it is a marker of oxidative stress and it has been found to be elevated in osteoporosis. Studies have found a direct correlation of homocysteine levels and bone loss. High serum homocysteine may be regarded as a factor that can reduce both bone mass and impair bone quality. It will help in the determination of the prognosis and need for additional therapy. In sum, collagen crosslink testing and homocysteine testing provided on 12/03/18 were likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 65-year-old female enrollee has requested reimbursement for collagen crosslink testing and homocysteine testing provided on 12/03/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. If the patient has received therapy, it would be appropriate to have a dual-energy x-ray absorptiometry (DEXA) at the end of the two-year treatment to assess the response to therapy. The value of monitoring therapy with the use of biochemical markers of bone turnover to aid in clinical decision is controversial. It is a test that can be variable and subject to timing, dietary intake as well as lack of assay standardization. Thus, collagen crosslink testing and homocysteine testing provided on 12/03/18 were not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 65-year-old male enrollee has requested authorization and coverage for PET (CPT code 78813) scan. The Health Insurer has denied this request indicating that the requested testing considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that overall, the use of fluciclovine PET is likely to be more beneficial in the management of the above patient when compared to standard techniques of evaluating this patients medical condition. 18F-fluciclovine was U.S. Food and Drug Administration approved in 2016 for the patients specific clinical scenario of suspected recurrent prostate cancer in patients with elevated PSA after prior therapy (Zanoni et al). The most recent National Comprehensive Cancer Network (NCCN) guidelines support its use in this setting (recurrent or persistent disease after initial treatment), specifically stating that F-18 fluciclovine PET/CT may be used to detect small volume disease in soft tissue. Performance is generally poor when PSA < 2.0ng/mL. Of note, the PSA for the above patient is 2.5 ng/mL.  The studies have shown that fluciclovine PET is more sensitive to detecting residual prostate cancer than bone scan or conventional computed tomography (CT) (Schuster, et al). Akin-Akintayo and colleagues specifically evaluated the use of fluciclovine PET/CT and its influence on postoperative radiotherapy treatment fields in patients with recurrent prostate cancer. They found that the results of a fluciclovine PET changed the radiation fields in 40.5% of the evaluated patients. Additionally, 4.8% of patients had radiotherapy withheld after the discovery of extra pelvic disease. There is a significant chance that fluciclovine PET will influence the patients salvage radiotherapy. All told, PET (CPT code 78813) scan is likely to be more effective for the evaluation of this patient as compared to conventional techniques. Therefore, for the reasons stated above, the requested services are likely to be more beneficial for evaluation 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 65-year-old male enrollee has requested authorization and coverage for PET (CPT code 78813) scan. The Health Insurer has denied this request indicating that the requested testing considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that there is support for the efficacy of the requested services in this clinical setting. The National Comprehensive Cancer Network (NCCN) guidelines support the use of PET scan in patients diagnosed with recurrent prostate cancer. The studies have shown the safety and efficacy of this technique in patients experiencing biochemical recurrence. Some patients have distant disease detected with this technique sparing patients side effects from treatment. As such, PET (CPT code 78813) scan is likely to be more beneficial than the available standard techniques for the evaluation of this patient. Therefore, for the reasons stated above, the requested services are likely to be more beneficial for evaluation 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 65-year-old male enrollee has requested authorization and coverage for PET (CPT code 78813) scan. The Health Insurer has denied this request indicating that the requested testing considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that a recent trial assessed the impact of PET (Axumin) scans on patients with a biochemical recurrence. It found that 61.2% of patients had a change in management as a result of the scan and the trial was stopped early. Of the changes, 40% required a change in radiation fields, and 35% underwent systemic therapy instead of radiotherapy (ASCO GU 2018). Recent medical literature have come to similar conclusions that PET scans can affect treatment after a prostatectomy (Wallitt, et al; Jani, et al). As such, PET (CPT code 78813) scan is likely to be of greater benefit when compared to the available conventional modalities for the management of this patients medical condition. Therefore, for the reasons stated above, the requested services are likely to be more beneficial for evaluation 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 1

A 47-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire upper airway stimulation system. 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 obstructive sleep apnea is an increasingly prevalent clinical problem with significant effects on both personal and public health. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. Hypoglossal nerve stimulation has been found to be safe and effective in a small subset of patients with obstructive sleep apnea who have failed continuous positive airway pressure, have nonconcentric airway collapse, an apnea-hypopnea index between 20 and 50, and a body mass index less than 32. With a body mass index of 28.75 and apnea-hypopnea index of 25.5, this patient meets the criteria for implantation with a hypoglossal nerve stimulator. He has failed continuous positive airway pressure, which is the gold standard treatment for obstructive sleep apnea, and he is at risk for untoward cardiac sequelae of untreated obstructive sleep apnea. Therefore, the requested hypoglossal nerve stimulation or Inspire upper airway stimulation system is likely to be superior over other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 47-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire upper airway stimulation system. 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 has obstructive sleep apnea and has a long palate. The nasal obstruction has been relieved since the sleep study was done in 2017, and an updated sleep study has not been performed. The patient has not been able to tolerate the continuous positive airway pressure device, but it is unclear if he has tried the device after the septoplasty. The Inspire device has been approved for the treatment of obstructive sleep apnea. At this point, the patient is not a candidate for the Inspire device given the palate appears to be the larger contributing factor to his sleep apnea compared to the base of tongue. If the patient fails treatment of the palate, and he continues to have sleep apnea and is intolerant of the continuous positive airway pressure, then the patient may become a candidate for the Inspire device at that point. At this time, the superior efficacy of the requested services has not been established. In sum, the requested hypoglossal nerve stimulation or Inspire upper airway stimulation system is not likely to be of greater benefit than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 47-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire upper airway stimulation system. 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 there is sufficient support for the requested services in this clinical setting. The records noted intolerance to the use of continuous positive airway pressure therapy. A sleep study documented symptoms of obstructive sleep apnea with an apnea-hypopnea index at the moderate to severe level of obstructive sleep apnea syndrome, with oxygen desaturation to 82%. Hypoglossal nerve stimulation therapy has been demonstrated to be an effective modality for the treatment of obstructive sleep apnea in patients with tongue-based obstruction. The medical evidence supports the requested services for the treatment of this patient. Thus, the requested hypoglossal nerve stimulation or Inspire upper airway stimulation system is likely to be of greater benefit than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 22-year-old female enrollee has requested authorization and coverage for spine nerve treatment, procedure codes 64634 and 64633. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the documentation submitted for review, the patient has failed to progress with conservative therapy, injections and physical therapy. Prior treatment with thoracic radiofrequency rhizotomy provided the patient with nine months of pain relief, improved function and the ability to pursue full-time studies as a nursing student.  The available literature indicates that in well-selected patients that respond to thoracic blocks and subsequently radiofrequency treatment, that 6-8 months of analgesia is a positive and favorable response that indicates repeat procedure is indicated. Therefore, spine nerve treatment, procedure codes 64634 and 64633 have been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.