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

Summary Reviewer 3

A 19-year-old male enrollee has requested reimbursement for procedure codes 86671 x 2 and 86021 x 3 performed on 2/14/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that this patient had symptoms concerning for inflammatory bowel disease, and has a diagnosis of ulcerative colitis. He was taking azathioprine, a therapy with significant potential adverse effects, and biologic therapy, which has serious potential adverse effects, was being contemplated.  Therefore, definitive diagnosis of inflammatory bowel disease was necessary in this case.  However, the American Gastroenterological Association guidelines and the American College of Gastroenterology guidelines for ulcerative colitis do not recommend the use of anti-Saccharomyces cerevisiae antibody (ASCA, CPT 86671) and anti-neutrophil cytoplasmic antibody (ANCA, CPT 86021) testing, or any other antibody testing, for diagnosis or management of ulcerative colitis. The American College of Gastroenterology guidelines specifically state that apooled sensitivity of antibody testing for diagnosis of ulcerative colitis is low, and such markers are not used for establishing or ruling out a diagnosis of ulcerative colitis.a American College of Gastroenterology guidelines for Crohnas disease do not recommend the tests either. Therefore, procedure codes 86671 x 2 and 86021 x 3 performed on 2/14/20 were not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1

A 71-year-old male enrollee has requested reimbursement for CPT 29999 performed on 8/27/18. 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 there is sufficient support for the services at issue in this clinical setting. This patient had continued anterior pain and pain with hip flexion after total hip arthroplasty. He had exhausted conservative care, and his provider recommended iliopsoas tendon lengthening. The procedure performed is a well-accepted surgical treatment for iliopsoas tendinitis after total hip arthroplasty in select patients. This patient had trialed medication and activity modification prior to surgery.  The surgery performed was likely to have been more beneficial than any available standard treatment. The only available standard treatment is open lengthening, which is a highly invasive intrapelvic procedure. Therefore, CPT code 29999 (left hip iliopsoas lengthening and left hip subspinal decompression) performed on 8/27/18 was likely to have been superior over other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 71-year-old male enrollee has requested reimbursement for CPT 29999 performed on 8/27/18. 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 this patient presented with persistent and function-limiting left hip pain following total hip arthroplasty in 2015. His pain interfered with activities of daily living. Clinical examination findings were consistent with iliopsoas tendonitis. He had failed long-term conservative treatment, including physical therapy, activity modification and medications. He underwent left hip arthroscopic surgery on 8/27/18 and was diagnosed with left hip iliopsoas tendinitis and anterior inferior iliac spine (AIIS) impingement. Surgery was performed to include left hip aspiration of synovial fluid for culture and sensitivity, left hip lysis of adhesions, iliopsoas lengthening, subspinal decompression, removal of ossified capsule, and left hip parallel capsulotomy and capsular closure. The current medical literature supports iliopsoas lengthening and subspinal decompression following failure of conservative treatment and prior to revision total hip arthroplasty. In sum, CPT code 29999 (left hip iliopsoas lengthening and left hip subspinal decompression) performed on 8/27/18 was likely to have been of greater benefit than other treatment options.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 71-year-old male enrollee has requested reimbursement for CPT 29999 performed on 8/27/18. 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 per the literature, impingement between the acetabular component and the iliopsoas tendon can cause anterior groin pain after total hip replacement. Treatment of the impingement can be nonoperative, arthroscopic, or open, with revision of the acetabular component. In the study by Filanti and colleagues, 35 patients with groin pain after total hip arthroplasty underwent preoperative evaluation, including injection of local anesthetic into the iliopsoas tendon sheath. An extensive arthroscopic debridement was performed. When there were signs of iliopsoas impingement, a transcapsular tenotomy was performed according to the Wettstein technique. The authors concluded that hip arthroscopy in treatment of anterior iliopsoas impingement is useful, more so than the open technique. Guicherd and colleagues noted that the procedure relieved pain in 92 percent of patients. Thus, CPT code 29999 (left hip iliopsoas lengthening and left hip subspinal decompression) performed on 8/27/18 was likely to have been more efficacious than other treatment options.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 


A 54-year-old male enrollee has requested reimbursement for inpatient mental health services provided from 1/26/16 through 3/24/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  He was not a danger to himself or others.  He was not delusional or paranoid, and had no hallucinations.  The patient remained depressed, but he showed overall slow and incremental improvements in hygiene, appetite and fluid intake, participation in on and off unit groups, and communication/interaction with others.  He was cooperative and medication compliant, and he tolerated medication changes well.  Although the patient received a course of electroconvulsive therapy while hospitalized, electroconvulsive therapy is most commonly administered on an outpatient basis and there is no indication that this was needed on an inpatient basis.  All told, inpatient mental health services provided from 1/26/16 through 3/24/16 were not medically indicated for the treatment of this patient.  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 48-year-old female enrollee has requested reimbursement for Oncotype DX Colon Cancer Assay performed on 4/28/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  It has been established that adjuvant chemotherapy is of benefit to patients with stage III (node positive) colon cancer.  It is much more controversial as to its value in stage II colon cancer, as in this patients case.  Most oncologists have made this decision based on specific pathologic features, such as a poorly differentiated histology, lymphovascular invasion, or presentation with obstruction or perforation.  Another approach is with the use of genetic panels.  The Oncotype DX Colon Cancer Assay is a 12-gene panel that predicts the risk of recurrence of the cancer in both stage II and III colon cancer.  This assay appears to predict the risk of recurrence with accuracy beyond what could be predicted from these usual pathologic features.  The medical evidence supports the use of Oncotype DX Colon Cancer Assay in assessing the potential value of adjuvant chemotherapy.  Therefore, Oncotype DX Colon Cancer Assay performed on 4/28/16 was likely to have been more efficacious than other methods of evaluating this patient.  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 48-year-old female enrollee has requested reimbursement for Oncotype DX Colon Cancer Assay performed on 4/28/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found this patient had stage II colon cancer. Although Oncotype DX Colon Cancer Assay provides prognostic data, to date it does not provide predictive data for the benefit of chemotherapy.  Per the medical evidence, the clinical utility of gene expression assays, including the 12-gene recurrence score, is uncertain, and information is lacking regarding the extent to which assay results do or do not classify patients into distinct groups with clinical relevance.  National Comprehensive Cancer Network guidelines state that there are insufficient data to recommend the use of multigene assays, such as the Oncotype DX Colon Cancer Assay, to determine adjuvant therapy.  In sum, Oncotype DX Colon Cancer Assay performed on 4/28/16 was not likely to have been of greater benefit 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 48-year-old female enrollee has requested reimbursement for Oncotype DX Colon Cancer Assay performed on 4/28/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found the medical evidence shows that adjuvant chemotherapy confers a survival advantage for patients with stage III colorectal cancer, but not for those with stage II disease.  Meta-analyses have not shown any survival advantage for 5-FU/leucovorin treatment in stage II patients.  The reasons for this conclusion are complex.  Stage II patients do well after surgery alone, so that the magnitude of the survival benefit conferred by adjuvant chemotherapy is small.  Additionally, randomized clinical trials to date have had too few stage II patients to discern a statistically significant advantage.  In contrast, the benefit for stage III patients is quite significant, and it is likely that stage II patients benefit as well. Therefore, subset analyses to identify those patients with prognostic features that may predict for chemotherapy benefit have been analyzed.  For example, oncologists consider adjuvant treatment for those stage II patients with T4 disease, obstructing lesions, and other biomarkers.  The Oncotype DX Colon Cancer Assay uses a reverse transcriptase-polymerase chain reaction assay for 12 genes in an algorithm that can be used to predict recurrence.  The medical evidence for the test is sufficient to allow its use to estimate the risk of recurrence for stage II patients when incorporated with other tests, such as standard pathology and microsatellite instability testing.  Thus, Oncotype DX Colon Cancer Assay performed on 4/28/16 was 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 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 61-year-old female enrollee has requested coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees left hip and buttock pain. The physician reviewer found that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The evidence based peer-reviewed literature support SI joint fusion in this clinical setting. Polly and colleagues concluded in their study that minimally invasive SI joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with SI joint dysfunction caused by degenerative sacroiliitis or SI joint disruptions. The authors noted that pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment. The International Society for Advancement of Spine Surgery (ISASS) policy statement for minimally invasive SI joint fusion provide specific indications for surgery. The criteria include: significant SI joint pain or significant limitations in activities of daily living because of SI joint pain; SI joint pain confirmed by at least three positive SI joint provocative tests; confirmation of the SI joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular SI joint block in the immediate post-injection period; failure to respond to at least six months of non-surgical treatment including medications, rest, physical therapy, and SI joint steroid injection or rhizotomy; and, additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been clearly considered, investigated and ruled-out. In this case, the patient presents with chronic left hip/buttocks pain with significant functional limitation. Detailed evidence of at least six months of reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted. Clinical exam findings have documented significant tenderness at the SI joint with six positive SI joint provocative tests. There is radiographic evidence of bilateral joint arthrosis with joint space narrowing. There is no imaging evidence of lumbosacral spine neural compression pathology. Multiple bilateral SI joint injections have produced 90% pain relief. The peer-reviewed supports the requested SI joint fusion as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy in this clinical setting. 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2


A 61-year-old female enrollee has requested coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees left hip and buttock pain. The physician reviewer found that the North American Spine Societys recommendations include that percutaneous sacroiliac joint fusion should only be considered when all inclusion criteria have been met. The authors state that due to the relatively moderate evidence, it is particularly critical that inclusion criteria are scrutinized and patient selection is executed with vigilance. In this case the patient meets North American Spine Society criteria for the proposed sacroiliac joint fusion. She has had at least 75 percent reduction of pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced intra-articular SIJ injection on two separate occasions. In addition, the postoperative CT scan on 11/5/15 shows no ongoing neural compression and no central canal or foraminal stenosis on the postoperative CT scan. This patient meets all NASS criteria for the proposed surgery. For these reasons, sacroiliac joint fusion surgery is 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 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: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3


A 61-year-old female enrollee has requested coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees left hip and buttock pain. The physician reviewer found that Polly and colleagues performed a randomized controlled trial of minimally invasive sacroiliac joint fusion using triangular titanium implants was compared to nonsurgical treatment at 12 months. A total of 148 patients with sacroiliac joint dysfunction were randomly assigned to minimally invasive sacroiliac joint fusion with triangular titanium implants or nonsurgical treatment. The study showed that minimally invasive sacroiliac joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with sacroiliac joint dysfunction caused by degenerative sacroiliitis or sacroiliac joint disruptions. Pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment. In addition, Whang and colleagues compared sacroiliac joint fusion using triangular titanium implants to nonsurgical management.  The conclusions were that at six-month follow-up the minimally invasive sacroiliac joint fusion using triangular titanium implants was more effective than nonsurgical management in relieving pain, improving function, and improving quality of life in patients with sacroiliac joint dysfunction due to degenerative sacroiliitis or sacroiliac joint disruptions. In this case, physical examination and multiple diagnostic sacroiliac injections have identified the pain generator. Therefore, evidence of neural compression on the imaging studies is not relevant. Based upon a review of the recent literature, the requested minimally invasive sacroiliac joint fusion has been established 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 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 31-year-old female enrollee has requested authorization and coverage for Forteo. 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 thesubmitted documentation supports the medical necessity of the requested medication. Osteoporosis is an increasingly widespread condition, and fractures are the most dangerous aspect of osteoporosis. Until recently, pharmacological options for the treatment of osteoporosis have been limited to antiresorptive agents, including the oral bisphosphonates. In humans, the elimination half-life of bisphosphonates is over 10 years. This raises concerns that in women of childbearing age, alendronate stored in the bone may be mobilized during pregnancy and taken up by fetal bones and may be potentially teratogenic. Newer treatment agents have become available over the past few years, including teriparatide (Forteo). Forteo is a recombinant form of the biologically active component of parathyroid hormone which has been shown to increase bone mass and prevent fractures in osteoporotic bone. The pharmacokinetics of Forteo have been characterized by rapid absorption and rapid elimination, resulting in a short total duration of exposure to the peptide. Therefore, Forteo (teriparatide) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 50-year-old male enrollee has requested authorization and coverage for Vemlidy. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B. A review of the record indicates the enrollee has a history of hepatitis B. On 5/9/17, the enrollee was noted to have hepatitis B complicated by cirrhosis. The record indicates the enrollee has been treated with Viread 300 mg daily. At that time, the provider recommended treatment with Vemlidy which has a better renal and bone safety profile than Viread. The Health Insurer indicates the requested medication is not medically necessary for treatment of the enrollees medical condition. At issue is whether the requested medication is medically necessary for treatment of the enrollees medical condition.I have determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 58-year-old female 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 chronic hepatitis C virus genotype 1b.  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested treatment with Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection. Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.