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

Summary Reviewer 1

The patient is a 51-year-old male with gastroesophageal reflux disease (GERD). Per the providers note dated 4/9/15, the patients symptoms include reflux, heartburn, emesis, and dysphagia. Esophageal manometry showed no classic abnormalities of esophageal motility or bolus transit on 3/9/15. A pH study with impedance showed elevated acid exposure, particularly when recumbent, and significant upright reflux with strong symptom correlation on 3/9/15. Per the provider, proton pump inhibitors have not been effective, and consistent and prolonged exposure to chronic acid due to uncontrolled GERD presents the possibility of progression to Barretts esophagus, which is considered a premalignant condition to esophageal adenocarcinoma. The patient has requested authorization and coverage for the LINX device. The Health Insurer has denied this request indicating that the requested procedure is considered investigational. Overall, there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The currently available peer-reviewed literature does not support the conclusion that LINX is more likely to be beneficial in this case than standard treatment including surgical fundoplication (Sheu, et al; Ganz). Further, the American College of Gastroenterology (ACG) guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). For these reasons, the requested LINX device is 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 requested procedure 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

The patient is a 51-year-old male under evaluation and management for gastroesophageal reflux disease (GERD). The patient has been treated with proton pump inhibitor (PPI) therapy along with over the counter antacids. He mainly complains of heartburn with occasional emesis and dysphagia. In addition, pH testing was borderline positive with acid reflux 5% of the time. Reflux was mostly in the recumbent position and reflux correlated well with symptoms. Esophageal manometry did not demonstrate any significant abnormalities. Upper endoscopy revealed a small hiatal hernia. There was no evidence of Barretts. The patient has requested authorization and coverage for the LINX device. The Health Insurer has denied this request indicating that the requested procedure is considered investigational. The US Federal Drug Administration (FDA) approved the LINX for lower esophageal sphincter augmentation for patients with inadequate symptom control with acid suppression therapy, with mild to moderate GERD, and a hiatal hernia less than 3 cm. The device is a ring made up of a series of magnets that have sufficient attraction to increase the lower esophageal sphincter (LES) closure pressure, but allow for food passage with swallowing. In the medical literature, Reynolds and colleagues compared the LINX procedure with laparoscopic fundoplication and found that GERD patients had similar control of reflux symptoms after both LINX and fundoplication. The inabilities to belch and vomit were significantly fewer with LINX, along with a significantly lower incidence of severe gas-bloat symptoms. In addition, Ganz and colleagues reported five-year cohort data establishing the durability of the device. All told, the requested LINX device is supported 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 procedure 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 Upheld

Summary Reviewer 3

The patient is a 51-year-old male with heartburn, vomiting, dyspepsia but was taking no acid suppression medication at the time of his 2/20/15 visit to his provider. Evaluation has included esophageal manometry with impedance testing that suggested a hiatal hernia but showed no classic dysmotilities. An esophagogastroduodenoscopy (EGD) with biopsies supported mild reactive changes at the gastroesophageal junction, H. pylori-negative mild reactive gastropathy, and peptic duodenitis. A 24-hour pH test identified both acid and non-acid reflux events with good symptom correlation with heartburn, regurgitation, and vomiting episodes. The patient has requested authorization and coverage for the LINX device. The Health Insurer has denied this request indicating that the requested procedure is considered investigational. The LINX device received U.S. Food and Drug Administration (FDA) approval for patients with diagnosed GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medica_l therapy for the treatment of reflux. The FDA noted that appropriate patient selection is important and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Currently, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative work-up for antireflux surgery. This patient has already undergone much of this pre-operative assessment which revealed relatively mild GERD, predominantly recumbent. However, the available records do not support ongoing use of acid suppression therapy, and as such is not considered medically refractory to acid blocker drugs. Accordingly, the requested LINX device is 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 requested procedure 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: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 37-year-old female enrollee has requested reimbursement for gene testing provided on 9/16/15. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees breast cancer. The physician reviewer found that Foundation One testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers than can help guide therapy decision making. The National Comprehensive Cancer Network (NCCN) guidelines have not been determined if molecular markers are useful in treatment determination and prognosis other than those established markers for breast cancer such as ER, PR and HER2. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. Given the lack of definitive support in the peer-reviewed literature, the gene testing provided on 9/16/15 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 37-year-old female enrollee has requested reimbursement for gene testing provided on 9/16/15. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees breast cancer. The physician reviewer found the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the patient has human epidermal growth factor receptor 2 (HER2) positive metastatic breast cancer. The options for treatment include Navelbine/Herceptin/Perjeta and Tykerb and Xeloda, and trastuzumab emtansine (T-DM1). Foundation One gene testing was not likely to aide in regimen selection. As such, the gene testing provided on 9/16/15 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 37-year-old female enrollee has requested reimbursement for gene testing provided on 9/16/15. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees breast cancer. The physician reviewer found that the patients with metastatic breast cancer encounter off-label therapies that may be supported by medical evidence. Von Hoff and colleagues studied 86 patients where the progression-free (PFS) survival on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has significant results for patients with stage IV tumors. This patient will be offered something off-label or a phase I/II clinical trial but with the results from molecular profiling offer a rational selection of the next regimen. In addition, more recent data on breast cancer also supports the use of Foundation One testing (Parker, et al). In sum, the gene testing provided on 9/16/15 was 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 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 57-year-old female with a history of lumbar degenerative changes and adjacent segment disease following a fusion at L4-5 with herniations L2 to S1 and degenerative spondylolisthesis at L3-4. The patient has requested authorization and coverage for laminectomy PLIF surgery and two (2) inpatient bed days. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient has a history of lumbar degenerative changes and adjacent segment disease following a fusion at L4-5. The records document low back pain. She has chronic herniations and neural foraminal stenosis at multiple levels from L2 to S1 and degenerative spondylolisthesis at L3-4.  A review of the current medical literature with regard to the laminectomy/decompression and PLIF indicates that it remains safe and effective, with a high percentage of pain relief and achieving a solid bony fusion. Therefore, laminectomy PLIF surgery and two (2) inpatient bed days are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 56-year-old female with a history of elevated liver enzymes, which she attributes to alcohol intake. Ultrasound of the abdomen on 7/01/19 showed heterogeneously increased liver echogenicity, likely hepatic steatosis, and a 4.0 cm hepatic cyst, which was previously 3.0 cm. Magnetic resonance imaging (MRI) of the abdomen with and without contrast was performed on 9/09/19. The physician reviewer found that per the American College of Radiology, the recommended test for liver lesions greater than 1 cm in size found on ultrasound is an MRI with and without contrast. This is supported by guidelines from the American Association for the Study of Liver Disease, which state that MRI can determine whether such lesions are hepatocellular carcinoma. The risk of hepatocellular carcinoma is increased in the setting of hepatic steatosis, even in the absence of cirrhosis, and the large liver lesion seen on ultrasound was concerning for hepatocellular carcinoma. Therefore, MRI of the abdomen, without contrast, performed on 9/09/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 61-year-old female who presented to her provider on 7/28/20. The patient has requested authorization and coverage for bilateral eyelid surgery, with dacryocystorhinostomy and probing of nasolacrimal duct, with or without irrigation, with insertion of tube or stent. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that Dacryocystorhinostomy is medically necessary in this case due to the symptoms of tearing and acquired stenosis of the lacrimal sac on examination. Upper eyelid ptosis repair is medically necessary in this case based on the functional complaints, photographs, and physical examination. The patient has well-documented functional complaints related to the eyelids drooping. The records document ptosis as evidenced by physical examination and photographs. The visual fields, history and photographs are compelling evidence of functional disability. There is sufficient support for the requested services in this clinical setting. Therefore, bilateral eyelid surgery, with dacryocystorhinostomy and probing of nasolacrimal duct, with or without irrigation, with insertion of tube or stent is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 50-year-old male who underwent open reduction and internal fixation of a distal radius fracture of the left arm. Postoperatively, the provider prescribed an intermittent limb compression device for edema control. The physician reviewer found that this patient underwent open reduction and internal fixation of a fracture of the distal radius associated with edema. The provider prescribed intermittent limb compression for edema control. Although this device is commonly used for lymphedema control after breast cancer surgery, edema of the upper extremity from a comminuted fracture of the distal radius can also be controlled by this device. Several studies have indicated that this device is safe and effective for upper extremity edema control. It can be used at home as well after discharge from the hospital. Based upon the demonstrated safety and efficacy of this device, it was reasonable, appropriate and medically indicated for the treatment of this patientas left arm edema. Therefore, the intermittent limb compression device provided on 5/17/19 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

The patient is a 45-year-old female with chronic low back pain, hip/buttock and tailbone pain and numbness and tingling above the knee. The onset of pain was atraumatic and began in November 2013. On 6/07/18, her pain was rated at 7 to 9/10 and was getting worse. She is status post L3-4 lumbar fusion and right sacroiliac arthrodesis. The patient has requested coverage for left sacroiliac joint fusion. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient. The available medical literature states that sacroiliac fusion may be recommended on a case-by-case basis as a last line of therapy (including either open or minimally invasive procedures) as treatment for sacroiliac joint infection, tumor involving the sacrum, disabling pain due to sacroiliitis due to spondyloarthropathy, or sacroiliac pain due to severe traumatic injury. The procedure may be required for multisegmental spinal constructs (i.e., scoliosis or kyphosis surgery). However, it is not recommended for mechanical low back pain, non-specific low back pain, sacroiliac joint disruption (in the absence of major pelvic fracture), degenerative sacroiliitis, or sacroiliac joint osteoarthritis. In this case, the submitted records do not indicate the patient has been diagnosed with the conditions which have quality evidence to support benefit from sacroiliac fusion. Thus, the superior efficacy of left sacroiliac joint fusion 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 3

The patient is a 45-year-old female with a history of transforaminal lumbar interbody fusion at L3-4 and minimally invasive right sacroiliac fusion. The patient has exhausted conservative treatment and has responded with 75% relief to two sacroiliac joint injections on the left. The patient has requested coverage for left sacroiliac joint fusion. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient.  This patient has failed conservative treatment for the left sacroiliac joint pain and had positive left sacroiliac blocks with 75% relief of pain. Sacroiliac joint degeneration is a common cause of chronic low back pain. Minimally invasive fusion procedures have demonstrated successful pain relief. Among these implants, the triangular titanium implants are more popular.  The recent medical literature has documented two-year follow-up of these procedures demonstrating meaningful clinical improvement and maintained pain relief as well as evidence of a solid fusion on imaging studies. Duhon and colleagues noted sacroiliac joint fusion using triangular titanium implants showed marked improvements in pain, disability and quality of life at two years. Thus, left sacroiliac joint fusion 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.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 40-year-old male has requested authorization and coverage for Tremfya. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. Patel and colleagues noted traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor (TNF) biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. In addition, patients treated with anti-TNF drugs may develop adverse events, such as infections, acute infusion and injection reactions, autoimmunity and cardiovascular effects. Tremfya (guselkumab) has been recently approved by U.S. Food and Drug Administration (FDA) for the treatment of adult patients with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy. Tremfya represents a promising therapy, providing an alternative mechanism of action with high efficacy and safety profiles, sustained total skin clearance, and rapid onset of effect in psoriasis patients who previously failed on Otezla. There is sufficient support for the requested medication in this clinical setting. Therefore, Tremfya is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1


A 45-year-old male enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees asthma. The physician reviewer found that bronchial thermoplasty is not generally accepted as standard of care for treatment of asthma. This procedure continues to be experimental or investigational. Bronchial thermoplasty is a procedure that uses a bronchoscope probe/catheter to provide thermal energy to the smooth muscle of the airway. In a publication by Thompson and colleagues, there was no difference in lung function indices (forced expiratory volume in 1 second) between those patients in the bronchial thermoplasty group and the control group who had visits or admissions into the emergency room. While the provider stated that the patient has had progressive decrease in his quality of life, there is a lack of clinical support to indicate that bronchial thermoplasty would improve the long-term functional outcome of the patients medical condition. For these reasons, the requested procedure is not likely to be superior to standard treatments available for treatment of this patients medical condition. Based upon the information set forth above, the requested procedure 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.