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

Summary Reviewer 


A 51-year-old female enrollee has requested authorization and coverage for magnetic resonance imaging (MRI). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees lower leg pain. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The standard of care criteria for MRI of the lower extremity is a six week trial of conservative treatment which may include rest, ice, compression and elevation (RICE), non-steroidal anti-inflammatory drugs (NSAIDs), narcotic and non-narcotic analgesic medication, oral or injectable corticosteroids, viscosupplementation injections, a physician directed home exercise program, cross-training, and/or physical therapy, or immobilization by splinting, casting or bracing. The clinical information submitted for review demonstrates that the patient has not met these criteria. There is no documentation of a physician supervised six week trial of conservative treatment. In sum, there is insufficient documentation of the required physical therapy participation or follow-up visits provided in the medical records. Based on the medical records submitted and the peer-reviewed literature, the requested MRI is not medically necessary for evaluation of the patients medical condition. For the reasons provided, the requested services are not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 53-year-old male enrollee has requested authorization and coverage for Otezla 30 mg tablets. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.  The physician reviewer found there is a lack of medical studies that demonstrate Otezla prevents joint injury on patients with erosive psoriatic disease. Moreover, while the diagnosis of psoriatic arthritis was documented in the provided records, there was inadequate symptomatology, a lack of radiologic studies and a lack of physical examination findings to support this diagnosis in this patient. Therefore, for the reasons stated above, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 56-year-old male enrollee has requested reimbursement for the anesthesia service provided on 9/7/16. The Health Insurer has denied this request indicating that the service at issue was not medically necessary for evaluation of the enrollees risk for colon cancer and polypectomy. The physician reviewer found that the patient has an ASA preoperative physical status classification score of 1. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in both clinical practice and in the research given a low preoperative physical status classification score (Heuss, et al; Trummel; Redondo-Cerezo, et al). While the billing office stated the patient failed moderate sedation, this prior failure of moderate sedation is not reflected in either the clinical records provided for review. All told, the anesthesia service provided on 9/7/16, was not medically necessary for evaluation of the patients medical condition. Based on the foregoing discussion, the service 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 Upheld

Summary Reviewer 

The patient is a five-year-old female with a medical history significant for torticollis. The patients parent has requested reimbursement for one-day stay (CPT code 99221) in the pediatric intensive care unit on 5/16/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that blunt abdominal trauma is the third most common cause of pediatric deaths, generally affecting the liver and spleen. Contusions, lacerations, and hematomas are the most likely injuries. Duodenal and pancreatic injuries are not unusual following direct blows to the abdomen or trauma involving bicycle handlebars. Children are at greater risk of renal injuries because of weaker abdominal musculature, decreased perirenal fat, and more flexible thoracic cage. A careful history and physical examination are essential, and when combined with the mechanism of injury, should provide guidance in diagnostic work-up and disposition. However, physical findings can be misleading, and repeated examinations may be necessary to determine need for further diagnostic investigation. Additional information can be gleaned from abdominal ultrasound, with abdominal CT reserved for more symptomatic patients (due to the radiation exposure). Specifically regarding renal trauma, organ preservation is of highest priority. Renal injuries are graded from I to V, with IV and V considered to be high grade and I and II to be low grade. Grade III represents a moderate injury. The trend in management is toward non-operative management, with short- and long-term monitoring for hypertension and persistent bleeding. In this patients case, she presented with stable hemoglobin, indicative of no ongoing blood loss. While it was reasonable to monitor her with serial examinations and laboratory evaluations, she was overall hemodynamically stable, with no evidence of impending circulatory collapse. She did not require acute inpatient admission and could have been safely managed at a lower level of care. Therefore, one-day stay (CPT code 99221) in the pediatric intensive care unit on 5/16/20 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 59-year-old female with a history of metastatic neuroendocrine pancreatic tumor. She is status post distal pancreatectomy, splenectomy, partial hepatectomy as well as radiofrequency ablation of hepatic metastases in February 2018. The physician reviewer found that Peptide receptor radionuclide therapy can be an effective treatment option for certain neuroendocrine tumors, improving progression-free survival. However, the treatment response is variable. Gallium dotatate PET/CT imaging has become a standard for the monitoring of certain neuroendocrine tumors, specifically somatostatin receptor imaging, and can help to identify patients in whom peptide receptor radionuclide therapy would be more effective. Gallium dotatate highlights the presence of somatostatin receptors in tumors, the entity to which the peptide receptor radionuclide therapy binds. It has been shown that baseline uptake on pre-treatment PET/CT predicts response to radionuclide therapy. In this case, the patient has failed traditional chemotherapy, evidenced by disease progression. She has been identified as a possible candidate for peptide receptor radionuclide therapy, and her provider recommended PET/CT prior to initiating treatment. There is sufficient support for the requested services in this clinical setting. Therefore, PET scan with CT for attenuation is medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1
A 57-year-old female requested reimbursement for magnetic resonance imaging (MRI) provided on 9/2/16.The Health Insurer has denied this request and reported that the service at issue was  considered investigational for evaluation of the enrollee who has a history of breast cysts. The physician reviewer found that there is support in the medical literature for the service at issue in this clinical setting. The positive family history, the dense tissue on mammography, and the presence of implants all limit the accuracy of mammography in this patient. MRI is the most sensitive means with which to screen for breast cancer and most patients with this risk level will undergo alternating MRI and mammography every six months. The use of MRI in this clinical setting has been advocated by many breast imaging organizations as well as the American Cancer Society. For these reasons, MRI performed on 9/2/16 was likely to be superior to other modalities available for the evaluation of this patient. Based upon the information set forth above, the service at issue was 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 Upheld

Summary Reviewer 2
A 57-year-old female requested reimbursement for magnetic resonance imaging (MRI) provided on 9/2/16.The Health Insurer has denied this request and reported that the service at issue was  considered investigational for evaluation of the enrollee who has a history of breast cysts. The physician reviewer found that according to the American College of Radiology appropriateness criteria for breast MRI, there is no data to support the use of breast MRI in the evaluation of breast pain as it does not meet the risk/benefit criteria. Cyclical pain is almost always due to hormonal fluctuation. The appropriate imaging examination for breast pain is mammography with possible ultrasound. Regarding the use of screening MRI for high risk patients, it is recommended for those patients with BRCA genetic mutations and their untested first degree relatives, women with additional genetic syndromes which increase the risk of breast cancer, women with a lifetime risk of greater than 20% and women who have received radiation therapy to the chest between the ages of 10 and 30. According to these criteria, this patient does not qualify for high risk MRI screening, as her lifetime risk is less than 20%. The patient has documented breast cysts on ultrasound. As such, MRI is not indicated for further evaluation of cysts. Diagnostic mammography with ultrasound is the appropriate imaging test for further evaluation of breast lumps/cysts. Therefore, in this patients case, MRI performed on 9/2/16 was not likely to have been more beneficial for the evaluation of this patients condition than the available standard imaging.Based upon the information set forth above, the service 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 57-year-old female requested reimbursement for magnetic resonance imaging (MRI) provided on 9/2/16.The Health Insurer has denied this request and reported that the service at issue was  considered investigational for evaluation of the enrollee who has a history of breast cysts. The physician reviewer found that in the last several years, the American Cancer Society (ACS) and the American College of Radiology (ACR) have established guidelines for the appropriate use of breast MRI. As per the ACS/ACR guidelines, those screening indications include screening for the high risk patient, screening the contralateral breast in a patient with a recently diagnosed breast malignancy, and screening in patients with breast augmentation. The accepted indications for diagnostic MRI of the breast is to evaluate extent of disease in patients with invasive, carcinoma or ductal carcinoma in situ (DCIS), in assessing invasion deep to the fascia, post lumpectomy with positive margins, or following patients with neoadjuvant chemotherapy. There is a lack of evidence to support the use of MRI as a surveillance tool rather than conventional mammography.  As noted by Weinstein, It is thought that there is inconclusive evidence regarding MRI screening of women with a personal history of breast cancer, lobular carcinoma in situ, atypical lobular hyperplasia, atypical ductal carcinoma, dense breast tissue, and lifetime risk levels of 15% to 20%.   The patient also has some breast pain and lumpiness in her breasts.  Breast pain is rarely associated with breast cancer, especially without a recognizable mass.  As noted in a recent survey by Howard, Initial imaging for women with breast pain increased the odds of subsequent clinical utilization and did not increase reassurance in ruling out malignancy. Overall, MRI studies of the breast are highly sensitive but have a relatively low level of specificity. The medical literature does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound. All told, MRI performed on 9/2/16 was not likely to have been of greater benefit over the standard modalities of evaluating this patients medical condition. Based upon the information set forth above, the service 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 Overturned

Summary Reviewer 

A 35-year-old female enrollee has requested reimbursement for arthroscopy surgery provided on 11/21/18. 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 this patient presented with chronic significant right hip pain with associated popping, clicking, and snapping, and repeated dislocations. Functional limitations were documented in activities of daily living. Clinical examination findings were consistent with radiographic evidence of femoroacetabular impingement and imaging findings of labral cartilaginous junctional delamination, confirmed at the time of arthroscopic examination. She had a history of bilateral hip dysplasia and no evidence of significant degenerative changes. Detailed evidence of long-term comprehensive nonoperative treatment and failure was submitted. She underwent complex right hip arthroscopic surgery with acetabuloplasty, femoroplasty, labral cartilaginous junctional refixation after abrasion chondroplasty, microfracture, synovectomy and capsular plication on 11/21/18. Current evidence-based medical literature supports this surgical intervention in this clinical scenario. Therefore, the arthroscopic surgery provided on 11/21/18 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 60-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that the most recent National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer summarize the published literature and discuss that dosimetric comparisons studies between proton therapy and intensity modulation radiation therapy (IMRT) do not predict accurately clinically meaningful endpoints. The NCCN guidelines acknowledge ongoing clinical studies and state that there is a lack of evidence supporting a benefit or decrement to proton therapy over IMRT for either treatment efficacy or long-term toxicity. All told, the peer-reviewed medical literature does not indicate the requested proton beam radiation therapy is likely to be more beneficial for treatment of this patients prostate cancer than 
conventional alternatives. Based upon the information set forth above, I have determined 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 60-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that there are studies comparing photons and protons in radiation therapy. The emerging technology committee of the American Society for Radiation Oncology (ASTRO) published an evidence-based review of proton beam therapy, which concluded that, although proton therapy holds promise, there is insufficient evidence that it is superior or even comparable to photon radiotherapy. Although proton therapy is an option for prostate cancer, there is a lack of data demonstrating substantial benefits over intensity modulated radiation therapy (IMRT). For these reasons, the requested proton beam radiation therapy is not likely to be more beneficial for treatment of the patients medical condition than any available modality. Based upon the information set forth above, I have determined 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 60-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that there is a lack of evidence in the medical literature to suggest that proton therapy for prostate cancer is associated with improved outcomes compared to standard treatment with intensity modulated radiation with image guidance. A recent comparative effectiveness study found no significant difference in toxicities between proton therapy and standard treatment (Sheets, et al). In addition, the National Comprehensive Cancer Network (NCCN) guidelines state that proton therapy for prostate cancer should not be performed outside of a clinical trial. Further, the American Society of Radiation Oncology (ASTRO) has also issued a position statement emphasizing that proton therapy should not be delivered for prostate cancer (Hahn, et al). Therefore, the requested proton beam radiation therapy is not likely to be more beneficial for the patients prostate cancer than standard therapy.  Based upon the information set forth above, I have determined 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 1

A 45-year-old female enrollee has requested reimbursement for FoundationOne CDx testing performed on 1/29/19. 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 FoundationOne CDx assay is a molecular assay that explores the mutations and other alterations of several hundred genes in an individuals cancer cells. The hope is that the assay will identify a target at which a chemotherapeutic agent could be directed for clinical benefit. Thus far, however, there is a lack of convincing evidence that the assay identifies useful targets often enough to be clinically beneficial. A randomized trial by Le Tourneau and colleagues did not demonstrate that picking a drug using such an assay was superior to picking a drug based on the oncologists judgment. Marquart and colleagues demonstrated that only a small minority of patients might benefit from using the assay to pick their therapy. Therefore, FoundationOne CDx testing performed on 1/29/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 45-year-old female enrollee has requested reimbursement for FoundationOne CDx testing performed on 1/29/19. 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 the molecular basis of neuroendocrine tumors remains poorly understood, and additional molecular predictors of outcome remain investigational. Per the National Comprehensive Cancer Network guidelines, more research is required before new molecular assays are routinely used in the clinic. A multinational consensus meeting of experts concluded that, to date, no single currently available biomarker is sufficient as a diagnostic, prognostic, or predictive marker in patients with neuroendocrine tumors. There are still treatment options available. Thus, FoundationOne CDx testing performed on 1/29/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 45-year-old female enrollee has requested reimbursement for FoundationOne CDx testing performed on 1/29/19. 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 the metastatic carcinoid or neuroendocrine tumor is a rare cancer that is generally not responsive to cytotoxic chemotherapy. There are studies trying single agents and combination therapy, but response rates are poor. There is no standard therapy, and it is preferable that patients be enrolled into a clinical protocol. In this case, the patients unusual tumor was submitted to Foundation Medicine for molecular testing to identify mutations that may be amenable to targeted therapies. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Von Hoff and colleagues performed a study of 86 patients, and the progression-free survival on regimen selected by molecular profiling was compared to progression-free survival on the last
chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. All told, FoundationOne CDx testing performed on 1/29/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 39-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 indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea. 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 stimulator has been found to be safe and effective in a small subset of patients with obstructive sleep apnea who have failed CPAP, have nonconcentric airway collapse, an AHI between 20 and 50, and a body mass index (BMI) less than 32. With a BMI of 31.1, AHI of 53.3 and nonconcentric airway collapse, this patient meets the criteria. He has failed CPAP, which is the gold standard treatment for obstructive sleep apnea. Therefore, hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System is likely to be of greater benefit than other treatment options. 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.