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

Summary Reviewer 

The patient is a 40-year-old female with a myriad of medical comorbidities, including Ehlers-Danlos connective tissue disease. She was evaluated as a second opinion on 3/26/21 due to concern regarding a suspected tethered cord. The physician reviewer found that the entity of occult tethered cord syndrome is controversial in the neurosurgery field. The patientas surgeon admits as much in his documentation. A number of publications are available in this area. The provideras review provides a thorough assessment of this knowledge in the field. In the provideras review, the only randomized controlled study was conducted as a pilot by Steinbok and colleagues in 2016. These investigators compared surgical (filum sectioning) and medical management of patients with urologic symptoms refractory to conservative treatments. All had normal conus positions and abnormal urodynamics. Only 21 patients could be accrued after eight years of trying. No significant differences were found between the groups. Overall, the data are challenging to interpret on the basis of the retrospective nature of the reports, the variability of the studies, the very small sample sizes, and the fact that the only prospective randomized study yielded a negative result regarding surgery. Most of the studies involved children, and this patient is an adult. A reasonable number of the patients in the noted studies one could argue had findings that made their cases not aocculta. This patient has a reported normal neurological examination by both neurology and her neurological surgeon. MRI scan of the lumbar spine is normal. The urodynamic report has no interpretation, and there is no clear assessment by a urological specialist. There is no independent neurology assessment that indicates tethered cord as a consideration. The data in support of surgical intervention in the form of filum sectioning is weak at best, and the diagnosis of occult tethered cord syndrome remains controversial. There is a lack of support for the requested services in this clinical setting. Therefore, lumbar spine surgery and other related services (codes 63200, 13160 and 69990) and the associated inpatient bed day are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 38-year-old male who has been found to be at risk for human immunodeficiency virus (HIV) by his clinical team. The patient has requested authorization and coverage for Descovy 200 mg-25 mg tablets. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. In this patientas case, Descovy is medically indicated, given the patientas reaction to Truvada. This patient reported significant nausea, diarrhea and insomnia while on Truvada. Descovy has been approved by the U.S. Food and Drug Administration for HIV prophylaxis in patients at risk. There is sufficient support for the requested medication in this clinical setting. Therefore, Descovy 200 mg-25 mg tablets are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 57-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. In addition, guidelines state that a High Priority for Treatment Owing to High Risk for Complications include patients with fibrosis of Metavir F2. In this case, the patient has a Metavir score of F2; hence, treatment is indicated. Therefore, Harvoni is medically necessary based on national guidelines. For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1


A 62-year-old male enrollee has requested reimbursement for gene testing for prostate cancer performed on 4/21/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the testing at issue was not likely to be more effective for this patient than other available treatment options. Bostrom and colleagues performed a literature review of the use of genomic biomarkers in the prognostication of prostate cancer outcome and prediction of therapeutic response. The authors indicated that genomic testing in prostate cancer is in its infancy and it is yet unknown how to use results in clinical practice. Moreover, the patient was determined to be at an intermediate risk, based on Gleason score of 7. Per National Comprehensive Cancer Network (NCCN) guidelines, viable options for treatment include prostatectomy or pre radiation androgen deprivation therapy, followed by radiation therapy. For the reasons provided, the genomic testing 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 services at issue were 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 Overturned

Summary Reviewer 2


A 62-year-old male enrollee has requested reimbursement for gene testing for prostate cancer performed on 4/21/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features such as the grade of tumor and PSA level. This helps guide the most appropriate therapy for patients taking into account their age and co-morbidities because many patients will not require therapy and may be observed without any intervention. The important features to recognize are Gleason score and PSA but these are imperfect and better prognostic biomarkers are needed. There are no robust biomarkers that can predict which cancers should be observed and which should be aggressively treated by radiation or surgery. The Prolaris test is an analysis of expression of genes (Cuzick, et al, 2012). It has been extensively tested retrospectively on a large cohort of prostate cancer patients (Cuzick, et al, 2011). It was also applied on another cohort and found to be predictive of prostate cancer aggressiveness (Cuzick, et al, 2014). The provider in this case had a reasonable discussion with the patient regarding treatment options and the Prolaris data may assist him and the patient to determine with the best treatment option. As such, the gene testing for prostate cancer performed on 4/21/15 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 services at issue were 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 62-year-old male enrollee has requested reimbursement for gene testing for prostate cancer performed on 4/21/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the gene testing for prostate cancer performed on 4/21/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Polaris test is a cell cycle proliferation score based on 31 genes and adds prognostic value in predicting risk of recurrence in patients undergoing definitive treatment. The test is not used to determine whether or not to treat but how aggressive to treat. Although not supported by the National Comprehensive Cancer Network (NCCN) guidelines, Prolaris is supported by the medical literature as a standard of care on how best to stratify patients that require some kind of definitive therapy. Based on the medical literature cited above, the services at issue were 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 services at issue were 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 42-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 1/19/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the breast tomosynthesis performed on 1/19/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms especially in women with dense breast tissue such as in this case. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in biopsies and callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional (2D) imaging alone. Thus, the addition of tomosynthesis was likely of greater benefit to the patient than had her exam been done with 2D imaging only. Based upon the information set forth above, the services at issue were 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 42-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 1/19/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the breast tomosynthesis performed on 1/19/16 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Ciatto and colleagues investigated the effect of integrated two dimensional (2D) and three dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls. Based on the support in the medical literature, the use of breast tomosynthesis 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 services at issue were 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 42-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 1/19/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as being diffusely dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, the breast tomosynthesis performed on 1/19/16 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 services at issue were 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 1

A 36-year-old female enrollee has requested reimbursement for gene testing (MaterniT21 Plus) performed on 2/03/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees pregnancy. The physician reviewer found the current standard of care recommends offering prenatal cell free fetal DNA testing to patients at increased risk.  This population is defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results.  Earlier testing increases the chance of a false-negative test due to inadequate amounts of genetic material at earlier gestational ages.  However, cell free testing has not been approved for use in multiple gestations due to limitations on accuracy.  Additionally, this patient underwent cell free fetal DNA testing when she was only seven weeks gestation, which is earlier than recommended.  All told, the superior efficacy of gene testing performed on 2/03/15 has not been established.  Based upon the information set forth above, the services at issue were 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 36-year-old female enrollee has requested reimbursement for gene testing (MaterniT21 Plus) performed on 2/03/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees pregnancy. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  As noted by the American College of Obstetricians and Gynecologists, regardless of the method, the accuracy of screening for aneuploidy is limited in multiple gestations.  With any method based on maternal blood, only a single composite result for the entire gestation is provided, with no ability to distinguish a differential risk between fetuses.  The data regarding the performance of cell free DNA screening in twin gestations are limited.  Although preliminary findings suggest that this screening is accurate, larger prospective studies and published data are needed before this method can be recommended for multiple gestation.  Cell free DNA screening is not recommended for women with multiple gestation.  Additionally, the patient underwent testing at just over seven weeks gestation, which is earlier than recommended.  Therefore, gene testing (MaterniT21 Plus) performed on 2/03/15 was not likely to have been of greater benefit than other modalities for evaluating this patient.  Based upon the information set forth above, the services at issue were 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 36-year-old female enrollee has requested reimbursement for gene testing (MaterniT21 Plus) performed on 2/03/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees pregnancy. The physician reviewer found the methods for fetal aneuploidy detection involve either invasive technique that place the fetus at risk or non-invasive prenatal testing which uses cell free fetal DNA from the plasma of pregnant women.  Cell free fetal DNA testing is an option that can be used as a primary screening test in women at an increased risk of aneuploidy.  However, the accuracy of screening for aneuploidy is limited in multiple gestation pregnancies.  The data regarding the performance of cell free DNA screening in two gestations are limited.  Thus, gene testing (MaterniT21 Plus) performed on 2/03/15 was not likely to have been more effective than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were 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 


A 48-year-old male enrollee has requested reimbursement for substance abuse intensive outpatient program (IOP) treatment provided from 7/26/16 through 8/19/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found according to the documentation submitted for review the patient presented with a history of alcohol dependence. At the time of admission, he denied cravings, post-acute withdrawal symptoms, or risk to himself or others. He was medically and psychiatrically stable. The patient did not present with emotional, behavioral, or cognitive issues that would require treatment at the IOP level of care. He had demonstrated the capability of making behavioral changes after 6/22/16 by seeking help and attending AA, having a sponsor, and remaining sober. He was highly engaged in the program, and on admission had insight into his behavior and recognized his triggers. He has a long history of AA attendance, as such he is aware of relapse prevention. He had his support systems in place. He did not require the structure of an IOP setting. His substance abuse treatment and relapse prevention could have been performed at the outpatient level of care. All told, the IOP treatment provided from 7/26/16 through 8/19/16 was not medically necessary for treatment of the patients medical condition.Therefore, the services at issue were 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 44-year-old male has requested authorization and coverage for total disc arthroplasty at the levels of L4-L5 and L5-S1. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient has ongoing axial back pain. Epidural steroid injections did not provide relief. There is no radiating component. The patient has attempted all reasonable nonsurgical treatments. There is a lack of treatment options in this setting. The medical literature supports the requested services in this patientas case. Therefore, total disc arthroplasty at the levels of L4-L5 and L5-S1 is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 44-year-old male has requested authorization and coverage for total disc arthroplasty at the levels of L4-L5 and L5-S1. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the Single-level lumbar disc replacement was U.S. Food and Drug Administration (FDA) approved in 2006 with the ProDisc-L based on good mid to long-term studies. The FDA approved the first two-level lumbar disc replacement in 2020, again with ProDisc-L implant showing good results. The study by Rasouli and colleagues involved a cohort of 159 patients. The authors concluded, aMultilevel total disc replacement preserves range of motion at the individual total disc replacement levels. Most significantly, the non-operative adjacent level maintains its preoperative range of motion at two to six years postoperatively. At up to six years of follow-up, there has been no need for revision or adjacent-segment surgery. Patients also demonstrate significant improvement in pain and disability at latest follow-up.a In a clinical case series involving 122 patients by Scott-Young and colleagues, multilevel total disc replacement for multilevel degenerative disc disease demonstrated favorable and sustained clinical outcomes at mid-term to long-term follow-up. In a comparison of a two-level versus one-level total disc replacement by Zigler and Ohnmeiss, patients undergoing two-level total disc replacement improved significantly postoperatively based on visual analog scales and Oswestry scores, and there were no significant differences in outcome scores when comparing one- and two-level total disc replacement. In sum, there is sufficient support for the requested services in this clinical setting. Therefore, total disc arthroplasty at the levels of L4-L5 and L5-S1 is likely to be more beneficial than any available standard therapy.