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

Summary Reviewer 2

A 22-year-old female enrollee has requested reimbursement for burn wound treatment provided on 1/10/19 (CPT 15273, 15274, 15277 and 15278). The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue. Suprathel is a full synthetic skin substitute. Hundeshagen and colleagues compared Mepilex Ag, a silver-impregnated foam dressing, and Suprathel, a DL-lactid acid polymer, in the outpatient treatment of partial-thickness burns in pediatric and adult patients. Per the authors, both dressings are feasible and efficacious for the outpatient treatment of minor and selected moderate partial-thickness burns. Rashaan and colleagues performed a prospective, observational study on 21 patients to evaluate adherence of Suprathel to the wound bed, reepithelialization time, grafting, wound colonization and infection, pain, dressing changes, length of hospital stay and scar formation. The authors found potential advantages of Suprathel treatment regarding pain and scar formation as compared to published results on (semi)synthetic dressings in the literature. No clear advantages were found regarding reepithelialization, need for grafting, wound colonization and infection and dressing changes. The authors concluded that randomized controlled trials are needed to evaluate the efficacy of Suprathel compared to other (semi)synthetic dressings in the treatment of partial thickness burns in pediatric patients. At this time, the medical evidence has not demonstrated that Suprathel is superior over other treatment options. Thus, burn wound treatment (CPT 15273, 15274, 15277 and 15278) provided on 1/10/19 was not likely to have been more beneficial than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 22-year-old female enrollee has requested reimbursement for burn wound treatment provided on 1/10/19 (CPT 15273, 15274, 15277 and 15278). The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the medical evidence supports a portion of the services at issue. Patients with burns benefit from early debridement and facilitation of rapid re-epithelialization (ideally less than three weeks) to prevent hypertrophic scar and the development of contractures and other adverse sequelae. While skin grafts have long been the gold standard for burn treatment, skin substitutes have a well-established role in the treatment of superficial and some deep partial thickness burns. Suprathel is a fully synthetic porous membrane that conforms to the underlying wound bed and promotes epithelialization. For partial thickness burns, Suprathel is superior to skin grafting since it avoids a donor site and significant pain. The ability to heal the wound and the ultimate appearance of the healed wound are equivalent to standard of care. For full thickness burns, however, it is inappropriate to use Suprathel. In this case, Suprathel was used on both partial and full thickness burns. Thus, burn wound treatment (CPT 15273, 15274, 15277 and 15278) for the partial thickness burns provided on 1/10/19 was likely to have been more beneficial than other treatment options. However, the superior efficacy of burn wound treatment (CPT 15273, 15274, 15277 and 15278) for the full thickness burns has not been established.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1
A 53-year-old female enrollee has requested reimbursement for collagen cross links testing performed on 11/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of fragility fracture The physician reviewer found that there is a lack of support for the superior efficacy of the services at issue in this clinical setting. The use of bone turnover markers such as collagen cross links testing performed in 2015 is not considered standard of care for the treatment of osteoporosis and is not routinely ordered. With a history of hip fracture, this patient could be treated with standard therapies such as bisphosphonates, selective estrogen receptor modulators (SERMs), Forteo, or Prolia. The standard of care, is to provide treatment based on other clinical findings. A study by Yoshimura and colleagues notes, Bone turnover markers (BTMs) were not significant predictors of bone loss, femoral osteoporosis, or osteoporotic fractures.  Furthermore, Vasikaran and colleagues reported that the clinical utility of BTMs for management of osteoporosis is not supported in the medical literature.   As such, there is a lack of support in the medical literature for the routine use of BTMs for those patients who are at risk of fractures. In sum, collagen cross links testing performed on 11/17/15 was not likely to have been more effective than the alternative measures available for the evaluation of this patients medical condition. 
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 53-year-old female enrollee has requested reimbursement for collagen cross links testing performed on 11/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of fragility fracture.The physician reviewer found that the evidenced based peer reviewed medical literature does not recommend collagen cross links laboratory testing for the management of osteoporosis. The available literature is inconclusive as to its efficacy and usefulness in this clinical setting. The current studies report that additional research needs to take place prior to making any recommendation for its use over the standard methods of evaluating and treating osteoporosis. Accordingly, collagen cross links testing performed on 11/17/17 was not likely to have been superior over the standard methods of evaluating this patients medical condition.

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 53-year-old female enrollee has requested reimbursement for collagen cross links testing performed on 11/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of fragility fracture The physician reviewer found that the use of bone turnover markers (BTMs) for the treatment of osteoporosis is still being determined.  There are large variations in the results using BTMs with only several being standardized. At this time, the interpretation of how to utilize BTMs are not standardized. National recommendations or guidelines are lacking as to its use in the evaluation and management of osteoporosis. There are multiple recent studies reviewing the use of BTMs. However, its clinical utility for monitoring osteoporosis is limited by inadequate appreciation of the sources of variability, by limited data for comparison of treatments using the same BTM and by inadequate quality control. IOF/IFCC recommend one bone formation marker (s-PINP) and one bone resorption marker (s-CTX) to be used as reference markers and measured by standardised assays in observational and intervention studies in order to compare the performance of alternatives and to enlarge the international experience of the application of markers to clinical medicine, (Vasikaran, et al). A recent review by Lee and Vasikaran did not include BTMs. The authors noted that Measurement of BTMs is currently not included in algorithms for fracture risk calculations due to the lack of data.  Accordingly, the literature fails to demonstrate that the collagen cross links testing performed on 11/17/15 was of greater benefit than the available standard therapy for the evaluation of this patients medical condition.

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 

The parent of a 13-year-old female enrollee has requested reimbursement for residential mental health treatment provided from 1/31/19 through 3/04/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2. The medical records indicate that the patient was not actively suicidal. She did not engage in self-harm behaviors but did have a reported history of passive suicidal ideation. With regards to functional status, the records support a score of 3. The patient has had issues with level of function due to mental illness in the past and relationship problems, but overall showed appropriate daily functioning while in treatment, including intact activities of daily living. In terms of comorbidity, the records support a score of 1. The patient did not have active medical problems or substance use that affected her primary psychiatric issues. With regards to level of stress of the recovery environment, the records support a score of 2. There is no indication of an unsafe home environment. In terms of level of support of the recovery environment, the records support a score of 2. The patients family was actively involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 3. It appears that the patient did not attempt any forms of the intensive treatment on an outpatient basis. In terms of acceptance and engagement of the patient, the records support a score of 2 to 3. The patient was hesitant to participate in treatment after admission to the residential treatment program. There was no indication that she was not participating in her outpatient treatment prior to the residential treatment center admission. With regards to acceptance and engagement of the parent, the records support a score of 2. The parent worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 17 to 18. This score correlates intensive outpatient services. Therefore, residential mental health treatment provided from 1/31/19 through 3/04/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 63-year-old female enrollee has requested reimbursement for computed tomography (CT) scan of the abdomen and pelvis performed on 12/11/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that there is sufficient support for the services at issue in this patients case. In the setting of acute/subacute abdominal pain with associated nausea and vomiting, the range of pathology is broad and includes gastrointestinal, biliary, pulmonary and genitourinary pathology. Imaging plays a key role in this setting to help direct management and treatment. CT of the abdomen and pelvis, preferably with oral and intravenous contrast, has been proven to improve the final diagnosis and management of patients presenting with abdominal pain. In this case, the CT of the abdomen and pelvis could have impacted patient management. Therefore, CT of the abdomen and pelvis performed on 12/11/18 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 61-year-old female enrollee has requested authorization and coverage for breath hydrogen/methane test (91065). The Health Insurer has denied this request and reported that the requested services are investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested services in this patients. In the setting of blood in the stool of a 61-year-old patient, a colonoscopy is typically warranted. The submitted records do not document that this study was performed. The clinical notes do not support that breath testing for small intestinal bacterial overgrowth is likely to be more beneficial for the evaluation of this patient than colonoscopy. If the patient has small intestinal bacterial overgrowth, options in lieu of breath testing could include empiric trials of Xifaxan and/or probiotics. Therefore, breath hydrogen/methane test (91065) is not likely to be superior over other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2

A 61-year-old female enrollee has requested authorization and coverage for breath hydrogen/methane test (91065). The Health Insurer has denied this request and reported that the requested services are investigational for the evaluation of the enrollees medical condition. The physician reviewer found that breath tests are based on the principle that metabolism of a test dose of carbohydrate substrate (e.g., lactulose) by the bacterial flora leads to the production of an analyte (hydrogen, methane), which is absorbed and ultimately excreted in the breath. Lactulose is a non-absorbable substance that is normally metabolized by gut bacteria in the colon with the production of hydrogen and/or methane. In theory, in individuals without small intestinal bacterial overgrowth, the administration of lactulose results in a single peak in breath hydrogen/methane within two to three hours due to the metabolism of lactulose by colonic flora. In patients with small intestinal bacterial overgrowth, administration of lactulose results in an early peak in breath hydrogen/methane levels due to metabolism by small bowel bacteria. In reality, this test is inaccurate. The main reason is that rapid transit of lactulose can occur. This will result in the presence of an early peak, misleading one to believe the patient has small intestinal bacterial overgrowth. A double peak is often not seen in cases of true small intestinal bacterial overgrowth. Therefore, there are many false positives and false negatives. In sum, a breath hydrogen/methane test (91065) is not likely to be of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3

A 61-year-old female enrollee has requested authorization and coverage for breath hydrogen/methane test (91065). The Health Insurer has denied this request and reported that the requested services are investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient presented with abdominal pain and gas after antibiotic use, potentially consistent with small intestinal bacterial overgrowth, although accurate and definitive diagnosis can be challenging. Hydrogen breath testing is the most widely available and widely used diagnostic test for small intestinal bacterial overgrowth. Testing for both hydrogen and methane increases the sensitivity of the breath test, and is a considerable improvement over hydrogen testing alone. Antibiotics are necessary for treatment if the results are positive, so confirmation of small intestinal bacterial overgrowth with breath testing can allow avoidance of unnecessary antibiotic use. Thus, breath hydrogen/methane test (91065) is likely to be more efficacious than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

A 29-year-old female enrollee has requested reimbursement for emergency services provided on 5/24/17. The Health Insurer has denied this request indicating the services at issue did not meet the prudent layperson criteria for treatment of an emergency medical condition. The physician reviewer found at issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition on 5/24/17. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. In the medical literature, Martin and colleagues noted that, allergic contact dermatitis (ACD) is an inflammatory skin disease that affects about 20% of the adult general population. The authors reported that first-line treatment includes topical emollients and anti-inflammatory agents and avoidance of the culprit allergen. In this case, the medical records do not indicate that the patient developed any urgent or emergent symptoms, such as interference with breathing or rapid swelling of the face or lips. A prudent layperson would not have sought immediate medical attention for the patients cutaneous eruption. Thus, the services provided on 5/24/17 were not required for the treatment of an emergency medical condition. Based on the foregoing discussion, the services at issue were not required on an emergent basis. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

The parent of a 15-year-old male enrollee has requested reimbursement for CPT code 95165, professional services for the suppression and provision of antigens for allergen immunotherapy from 2/10/15 through 2/12/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found serial dilution end point titration technique of allergen testing is an alternative to skin prick testing. According to Boyles, serial endpoint titration showed a higher degree of sensitivity in evaluating skin response in less sensitive reactors  Per Boyle, identifying patients who are less sensitive reactors is important, so that they can be started on immunotherapy.  Per the current medical evidence, serial dilution endpoint titration is an acceptable alternative to skin prick testing for identification of allergens, with the goal of desensitizing patients and eliminating need for sustained anti-allergy medications.  In sum, the services at issue were likely to have been of greater benefit than other modalities.  Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


The parent of a 15-year-old male enrollee has requested reimbursement for CPT code 95165, professional services for the suppression and provision of antigens for allergen immunotherapy from 2/10/15 through 2/12/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  Allergen immunotherapy is a long-term treatment that decreases symptoms for many people with allergic rhinitis, allergic asthma, conjunctivitis or stinging insect allergy.  Allergy shots decrease sensitivity to allergens and often lead to lasting relief of allergy symptoms even after treatment is stopped.  Indications for allergen immunotherapy include allergic asthma and rhinitis, conjunctivitis, as well as venom-induced anaphylaxis.  In this patients case, the records do not support the services at issue.  Without a diagnosis of asthma, rhinitis, conjunctivitis or anaphylaxis, the services at issue cannot be recommended.  In sum, CPT code 95165, professional services for the suppression and provision of antigens for allergen immunotherapy from 2/10/15 through 2/12/15 were not likely to have been of greater benefit than other treatment options.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


The parent of a 15-year-old male enrollee has requested reimbursement for CPT code 95165, professional services for the suppression and provision of antigens for allergen immunotherapy from 2/10/15 through 2/12/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found there is sufficient evidence in the medical literature to support the use of home allergy immunotherapy.  The current medical evidence supports the services at issue in this patients case.  Per the medical records, home administration of allergens immunotherapy was medically appropriate.  Therefore, CPT code 95165, professional services for the suppression and provision of antigens for allergen immunotherapy from 2/10/15 through 2/12/15 was likely to have been more efficacious than other methods of treating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1

A 63-year-old female enrollee has requested reimbursement for ExoSym kinetic orthosis for right knee provided on 9/12/16. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees right knee pain. The physician reviewer found that the ExoSym kinetic orthosis is a customizable energy-storing device that is designed to support and protect an array of lower extremity limb injuries. However, at this time, there is a lack of evidence to support that the published results can be duplicated on a reliable basis. Until quality data becomes available, this orthosis does not have adequate support for use outside of a clinical trial. Accordingly, the ExoSym kinetic orthosis for right knee provided on 9/12/16 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.