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

Summary Reviewer 

The patient is a 49-year-old female with small intestinal bacterial overgrowth. Per the provider note dated 4/27/17, she has a history of gastroesophageal reflux disease (GERD), iron-deficiency anemia, hypertension, and irritable bowel syndrome. A hydrogen and methane breath test on 3/24/17 showed baseline scores of 8 parts per million (ppm) of each gas. There was an increase of 85 ppm over baseline to 101 ppm. As the increase was over 33 ppm, this was considered severe bacterial overgrowth of the small intestine. Per the provider note dated 4/3/17, she presented with gas and bloating and a low vitamin D level. She was started on Xifaxan 200 mg three times daily for 28 days.  The patient has requested reimbursement for Xifaxan 200 mg tablets administered on 4/10/17 and 4/19/17. The Health Insurer has denied the request for reimbursement and reported that it was not medically necessary for treatment of this patients medical condition. This denial is the subject of this appeal and determination.Xifaxan has been proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief (Scarpellini, et al; Gatta, et al). For bacterial overgrowth, eradication was demonstrated in 80% versus 54% for placebo (Scarpellini, et al). The medication had greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones (Pimentel, et al; Lauritano, et al).  Results were sustained for several weeks after treatment. A recent study by Boltin and colleagues has corroborated this finding. A prospective trial of patients, with irritable bowel syndrome and a positive breath test, found that 86% responded to Xifaxan, and symptoms were reduced as well (Moraru, et al). The dose and duration of 600 mg per day for 28 days are consistent with regimens used in studies (Gatta, et al).  Therefore, Xifaxan 200 mg on 4/10/17 and 4/19/17 were medically necessary for the treatment of this patients small intestinal bacterial overgrowth. For the reasons stated above, the medication at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 19-year-old male enrollee has requested reimbursement for the substance abuse subacute residential treatment services provided from 7/11/15 through 8/8/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees substance abuse, anxiety, and depression. The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general, community intervention settings optimize treatment gains and referrals to higher level of care ordinarily progress in a step-wise fashion. However, bypassing intermediate levels of care for episodic placement in more restrictive settings is often clinically appropriate for those with serious psychiatric disease and addictive illness. It is impossible for even the most comprehensive of standard placement algorithms to account for the myriad of variables unique to complex cases. Accordingly, we entrust physicians and therapists working directly with the patient population to interpret and apply clinical guidelines and patient placement criteria, in consideration of clinical presentation and treatment needs, to determine the appropriate level of care and length of stay. The American Psychiatric Association (APA) states that decisions regarding the site of care should be based on the patients ability to cooperate with and benefit from the treatment offered, refrain from illicit use of substances, and avoid high-risk behaviors as well as the patients need for structure and support or particular treatments that may be available only in certain settings. In this particular case, the patient was unable to maintain sobriety in his current environment. He was non-adherent with psychotropic medication and was cognitively impaired. He was demonstrating new onset psychotic symptoms that may have been secondary to drug use or the manifestation of a formal thought disorder. On 7/10/15, the patient was in total denial while his behaviors were described as angry, labile and paranoid. Based on the patients burgeoning psychosis, abysmal insight and lack of any significant progress in the outpatient setting, 24-hour substance abuse residential treatment program services were indicated. Further, the required level of supervision and treatment could not have been conducted at a less restrictive setting. Moreover, the residential program was recommended by a board certified psychiatrist following a failed attempt of outpatient treatment. All told, the substance abuse subacute residential treatment services provided from 7/11/15 through 8/8/15 were medically necessary for treatment of this patients medical condition. Therefore, the services at issue were 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 57-year-old female enrollee has requested reimbursement for Afirma Thyroid FNA Analysis performed on 12/4/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that although FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate (Alexander, et al). Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision (Miller, et al). The Afirma Thyroid FNA Analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is suggestive of a benign nodule and can preclude such surgical procedures (Duick et al). In this case, the patient underwent an Afirma gene classifier analysis which was suggestive of a benign nodule, and she was able to avoid an unnecessary surgery. For the reasons provided 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 2


A 57-year-old female enrollee has requested reimbursement for Afirma Thyroid FNA Analysis performed on 12/4/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.The physician reviewer found in this case, the patient presented with a thyroid nodule with suspicious features. In this clinical setting the risk of malignancy may be as high as 70-90% (Haugen, et al). The cytopathology was consistent with atypia of undetermined significance (AUS), therefore, the specimen was sent to Afirma Thyroid FNA Analysis, which was consistent with a benign finding. The Bethesda System recommends a second fine needle aspiration (FNA) when the cytopathology is consistent with AUS. The 2015 American Thyroid Associations guidelines indicate that for nodules with AUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. FNA with molecular testing is considered standard of care in this clinical setting. Proceeding directly to the Afirma Thyroid FNA Analysis prevented a second biopsy and or diagnostic thyroidectomy with its possible complications. All told, the Afirma Thyroid FNA Analysis performed on 12/4/14 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 57-year-old female enrollee has requested reimbursement for Afirma Thyroid FNA Analysis performed on 12/4/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the Afirma Thyroid FNA Analysis performed on 12/4/14 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the initial biopsy report was indeterminate. The Afirma testing revealed a benign result. This was a determining factor in delineating the further course of action to assess whether a surgical procedure was warranted. Afirma testing is considered standard protocol on FNA samples performed on thyroid nodules. In sum, the testing at issue 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: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


The submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has requested coverage for finasteride for the treatment of androgenetic alopecia.  While finasteride has been shown to regrow hair in this condition, its use is considered cosmetic with no effect other than improving the appearance of the patient. Consequently, its use is not considered to be medically indicated.  All told, the requested finasteride tablets 5 mg are not medically necessary for the treatment of this patient.  Therefore, the requested medication is 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 55-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 11/2/15.  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 that the breast tomosynthesis performed on 11/2/15 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 documentation submitted for review and 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 2

A 55-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 11/2/15.  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 that the American College of Radiology (ACR) has recommended tomosynthesis be removed from the investigational category due to the advantages it affords radiologists in interpreting mammograms. This tomographic method allows radiologists to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional (2D) imaging protocol was likely of greater benefit to the patient than 2D imaging alone. 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 55-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 11/2/15.  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 that the breast tomosynthesis performed on 11/2/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue in the routine screening population. According to the study by Ciatto and colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis (Skaane, et al). Given the support above, the breast tomosynthesis performed on 11/2/15 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: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 68-year-old female enrollee has requested authorization and coverage for Repatha 140 mg/ml. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the request for Repatha 140 mg/ml is medically necessary for treatment of the patients medical condition. Based on the records provided, the patient is a 68-year-old female with known coronary disease, dyslipidemia and documented inability to tolerate several statin medications. Most recently, she is treated with a maximally tolerated low intensity statin, fluvastatin once weekly. Her LDL cholesterol on the above maximally tolerated statin is not at goal and there is evidence of progression of coronary disease. Repatha (evolocumab) is a PCSK9 inhibitor approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. The documentation submitted for review shows that the patients LDL is not at goal and that she has tried and did not tolerate several statins including atorvastatin, rosuvastatin and fluvastatin in addition to Zetia in combination with a statin medication. Therefore, the medical necessity for treatment with Repatha 140 mg/ml has been established in this clinical setting.  Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 44-year-old male enrollee has requested reimbursement for inpatient admission from 4/15/15 through 4/19/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition The physician reviewer found the current medical evidence supports the medical necessity of a portion of the services at issue.  In this case, the patella tendon reconstruction was carried out using allograft for patellar stabilization.  The MRI scan was performed on 4/14/15, so the diagnosis was known on 4/15/15.  The injury of 4/15/15 exacerbated pain, but no surgery was performed until 4/17/15.  In this clinical setting, two days of inpatient hospital stay was appropriate and medically necessary.  In this patients case, the diagnostic testing performed prior to surgery could have been performed as an outpatient. Therefore, hospitalization on the day of surgery and on the day after surgery, 4/17/15 through 4/18/15, were medically indicated.  The hospitalization prior to surgery was not.  As such, inpatient admission from 4/17/15 through 4/18/15 was medically necessary.  However, the records fail to demonstrate the medical necessity of the remaining dates of service at issue.  Therefore, I have determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 38-year-old male who has a history of idiopathic thrombocytopenic purpura and a pulmonary embolus in November 2018 for which he was on apixaban anticoagulation. The patient has requested authorization and coverage for the RT300 FES Therapy System. The Health Insurer has denied this request and reported that the requested equipment is not medically necessary for the treatment of this patient. The physician reviewer found that this patient had residual right-sided greater than left-sided weakness following multiple insults to the brain in mid-2019. He underwent extensive rehabilitation that included multidisciplinary therapies and made significant functional improvements. A functional electrical stimulation cycle ergometer was prescribed for home use. The functional electrical stimulation cycle ergometer that was prescribed for home use is not medically necessary for treatment of the patientas condition. The medical literature has not shown that the device improves neurological, functional or health outcomes in a clinically significant manner following stroke, whether ischemic or hemorrhagic, or whether cerebral or cerebellar. A recent meta-analysis by Ambrosini and colleagues did not find that functional electrical stimulation-induced cycling improved outcomes better than usual care for subacute stroke survivors. The use of this type of device is not an evidence-based component of stroke management, rehabilitation or prevention of complications following stroke as noted on multiple recent reviews. Therefore, the requested RT300 FES Therapy System is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 64-year-old male enrollee has requested reimbursement for PET scan performed on 8/31/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. The use of positron emission tomography (PET) scans in staging and restaging colon cancer has been proven to be more sensitive for residual or recurrent colon cancer than computed tomography (CT) or magnetic resonance imaging (MRI) alone. The physiologic activity of metastases or local recurrence makes PET a more sensitive test for tumor than conventional imaging. The PET scan on 8/31/18 followed a conventional CT and was indicated for the patients condition. Therefore, PET scan performed on 8/31/18 was likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 64-year-old male enrollee has requested reimbursement for PET scan performed on 8/31/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found taht the submitted documentation fails to demonstrate the superior efficacy of the services at issue. The records document that the patient was diagnosed with a hepatic flexure malignancy. On 7/27/18, computed tomography (CT) scan of the abdomen and pelvis was performed. While the use of positron emission tomography/computed tomography (PET/CT) scanning is becoming increasingly common in the work-up of malignancies, the current data does not support its routine use in staging colon cancer. In this patients case, he already had a staging laparotomy and CT scan, with no evidence of spread of disease. PET scanning was not indicated in this clinical setting. In sum, PET scan performed on 8/31/18 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 64-year-old male enrollee has requested reimbursement for PET scan performed on 8/31/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that complete staging of colorectal cancer is necessary to determine a patients treatment strategy. Imaging is utilized to evaluate for the presence of distant metastases, as this will impact management. Positron emission tomography/computed tomography (PET/CT) scan is most commonly used to evaluate for nodal and distant metastatic disease and has a sensitivity of approximately 89% and specificity of 64% in this setting. PET/CT can also exclude additional sites of metastases aside from more common pulmonary and hepatic metastases. In this case, PET/CT was performed prior to initiating chemotherapy to assess for metastatic disease. Thus, PET scan performed on 8/31/18 was likely to have been more effective than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summaryi