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

Summary Reviewer 3


The parent of a 12-year-old male enrollee has requested authorization and coverage for Remicade 400 mg for two weeks and then once monthly for one year. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees juvenile dermatomyositis (JDMS). The physician reviewer found the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based on the documentation submitted for review, the patient has juvenile dermatomyositis which is moderate to severe and a biologic such as Remicade (infliximab) would likely be beneficial for this patient. Moreover, infliximab has been shown to be safe and effective in children with juvenile dermatomyositis. Riley and colleagues assessed the response of five refractory juvenile dermatomyositis patients to infliximab. The authors reported Improvements in all five patients as shown by positive changes in physician visual analogue scale (VAS), Childhood Myositis Assessment Score (CMAS), Childhood Health Assessment Questionnaire (CHAQ), joint range of movement and, in some, regression of calcinosis and skin signs. There were no major side effects observed with addition of infliximab to the therapeutic regime. For the reasons provided, the requested services are 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 1
A 68-year-old male requested authorization and coverage for UroLift procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees benign prostatic hyperplasia (BPH). The physician reviewer found that the requested procedure (UroLift system) is a minimally invasive approach to treating BPH that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. Recent clinical trials, including prospective, sham controlled, randomized studies, have shown that this procedure is safe and effective in relieving lower urinary tract symptoms due to BPH without significantly compromising sexual function.  Compared with transurethral resection of the prostate and photoselective laser vaporization of the prostate, UroLift is a minimally invasive procedure without a requirement of general anesthesia and with a potentially shorter operative time.  As such UroLift procedure is likely to be more effective than other options for the treatment of this patient Therefore, for the reasons stated above, the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 68-year-old male requested authorization and coverage for UroLift procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees benign prostatic hyperplasia (BPH). The physician reviewer found that there is sufficient support in the medical literature for the requested procedure in this clinical setting. The UroLift procedure has distinct advantages over other traditional surgical treatment in that it is outpatient, offers immediate improvement in the voiding pattern, often involves no significant blood loss and has less sexual adverse events such as retrograde ejaculation. The American Urological Association does not consider UroLift as an experimental procedure and supports its use in the treatment of patients who are diagnosed with BPH. All told, UroLift procedure is likely to be more efficacious than other treatment options for the treatment of this patient. Therefore, for the reasons stated above, the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 68-year-old male requested authorization and coverage for UroLift procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees benign prostatic hyperplasia (BPH).The physician reviewer found that UroLift has been approved by the U.S. Food and Drug Administration and is considered a treatment option by the American Urologic Association Residency Education program on BPH management. This treatment option is most beneficial in men who wish to avoid retrograde ejaculation, increased risk of bleeding and retention, which are normally found in prostatic vaporization, or transurethral electro-resection of the prostate (TURP). A recent publication has reported the five year follow up of a pivotal trial of UroLift with equal efficacy and lower complications compared to historical TURP analogous data. Accordingly, UroLift is likely to be more efficacious than other alternatives for treatment of this patients symptoms. 
Therefore, for the reasons stated above, the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 


A 27-year-old male enrollee has requested authorization and coverage for venlafaxine extended release (ER) 450 mg per day. The Health Insurer has denied this request indicating that the requested dosage is not medically necessary for treatment of the enrollees generalized anxiety disorder.   The physician reviewer found that although fairly uncommon, the medical literature supports venlafaxine doses of 450 mg daily. According to the American Psychiatric Association (APA), venlafaxine exhibits linear kinetics over a dosage range of 75-450 mg/day. Further, the APA recognize that a large amount of data from randomized controlled clinical trials suggest that patients who do not respond to lower dosages often benefit from dosage increases. The presence of obsessive compulsive disorder (OCD), which typically necessitates supra-therapeutic dosing of serotonergic enhancing medication in clinical practice, further supports the requested treatment. Indeed, the APA clinical practice guideline referenced a study that demonstrated sustained clinical response for previous non-responders, without tolerability issues, of venlafaxine doses up to 450 mg daily. Considering that this patients medical records demonstrate clinical stability on the current regimen, physician recommendation, endorsement from the APA and the peer-reviewed literature base, high-dose venlafaxine therapy represents a safe, appropriate treatment consistent with good medical practice. Continuation of the therapy would be reasonably expected to maintain the patients wellness and prevent a more serious episode of illness. As such, the requested venlafaxine extended release 450 mg per day is medically necessary for treatment of the patients behavioral health condition. Based on the foregoing, the requested dosage 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 

The patient is a 41-year-old male with a history of chronic left knee pain and swelling on both the medial and lateral aspects.  The patient has requested reimbursement for synovectomy performed on 6/19/20 (CPT 29876). The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found the article by Goyal and colleagues pertains to chronic synovitis involving a single large joint. In this study, 61 patients with chronic mono-articular synovitis of the knee were followed for two years and underwent x-rays, MRI scans, and arthroscopic synovectomy with histopathological examination. The histopathological examination showed chronic nonspecific inflammation in 28 patients (46%). Felson and colleagues discussed the relationship of untreated chronic synovitis to osteoarthritis, indicating the medical necessity of such treatment. In this patients case, the synovectomy was medically necessary for establishing a diagnosis as well as symptomatic relief by resecting hypertrophic synovium. The patient presented with chronic pain and swelling of one knee for a year. There was a loose body on the MRI that turned out to be hypertrophied synovium with calcification. The joint effusion and restricted range of motion (0-90) was associated with chronic synovitis that warranted arthroscopic synovectomy for a definitive diagnosis as well as treatment. The diagnosis was chronic non-specific synovitis, which was treated appropriately. Therefore, synovectomy performed on 6/19/20 (CPT 29876) was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer

The patient is a 17-year-old male who was admitted on 6/22/18. The submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient was admitted to the treatment center due to some oppositional behaviors as well as some anxiety symptoms. He noted daily anxiety symptoms with the majority of these symptoms related to his return home. The therapy and treatment providers were largely focused on his relationship with his family and the anxiety that this caused him. The records did not indicate that the patient expressed serious anxiety in regards to social anxiety concerns or school performance. He was not noted to have aggressive behaviors or self-harm behaviors during his stay. His risk of self-harm and danger was consistently rated as none throughout his stay. The patient denied serious depression or anhedonia during his stay. The documentation does not support failure of intensive outpatient therapy, partial hospital program therapy or cognitive behavioral therapy. 

Per the records, this patient had relational issues with his family. Initial recommendations included working on parental communication in psychotherapy. It is not clear what type of family therapy the family had engaged in on outpatient basis. Functional family therapy has proven highly successful in decreasing violence, drug abuse/use, conduct disorder and family conflict and in reducing residential treatment placements and juvenile involvement with the corrections system. Functional family therapy is typically administered on an outpatient basis, and the records indicate that this type of treatment would have been appropriate for the patient and his family on an outpatient basis. This patient also had functional impairment due to oppositional behavior, and this was one of his primary diagnoses. The evidence base regarding childrens mental health treatment has shown that treatment outside of a residential setting is effective and appropriate. In this patients case, due to his lack of severe symptoms and dangerous behaviors, less restrictive care was appropriate especially as related to family therapy as well as cognitive behavioral therapy for his anxiety symptoms. Due to the patients overall mild symptoms and lack of evidence to support failure of less restrictive treatments, the services at issue were not medically indicated. Thus, mental health residential treatment provided from 7/11/18 through 8/06/18 were not medically necessary 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 32-year-old female enrollee has requested reimbursement for laboratory testing performed on 6/26/19. 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 this patient has a history of a left lower extremity deep vein thrombosis felt to be provoked in the setting of trauma, for which she was placed in an orthopedic boot, and travel. There is no family history of blood clots. Most experts recommend testing for all five inherited thrombophilias (protein S, C, and antithrombin deficiencies, factor V Leiden and prothrombin gene mutation) and antiphospholipid syndrome in those who are younger than 45 years of age. In an analysis by Weingarz and colleagues of unselected patients with venous thromboembolic event and a median age of 43 years, at least one thrombophilic disorder was identified in half of the cohort. This patient is young and had a venous thromboembolic event, and although provoked, meets criteria for more intense testing. Therefore, laboratory testing performed on 6/26/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2

A 32-year-old female enrollee has requested reimbursement for laboratory testing performed on 6/26/19. 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 when performing thrombophilia screening, while the probability of a positive assay is higher in patients with a history of thrombus, the information provided does not help to inform future management. Various professional organizations have published guidelines indicating that routine thrombophilia screening in patients presenting with thrombosis should not be performed. In this
case, results of the thrombophilia screen is not likely to justify an evidence-based modification of this patients management. Furthermore, the consulting provider indicated that the deep vein thrombosis was considered to be a provoked event. The medical evidence does not support thrombophilia screening in this setting. In sum, laboratory testing performed on 6/26/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3

A 32-year-old female enrollee has requested reimbursement for laboratory testing performed on 6/26/19. 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 extensive literature supporting the services at issue in this clinical setting. The factor V mutation has the potential to induce hypercoagulopathy in the right environment, such as a long airplane flight or automobile trip, as in this patients case. Importantly, prothrombin G20210A mutation adds to this risk, such that compound heterozygous patients can have up to 20-fold increased odds of developing deep vein thrombosis. The testing performed was likely to directly alter the treatment recommendation. If this patient was found to be a carrier of multiple mutations predisposing to thrombosis, then a recurrent thrombotic event could be prevented with drugs and/or activity. Thus, laboratory testing performed on 6/26/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

A 57-year-old female enrollee has requested authorization and coverage for the injectable medication Euflexxa. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees knee pain. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Campbell and colleagues conducted a systematic review of overlapping meta-analyses comparing intra-articular hyaluronic acid with other nonoperative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. This patient presents with chronic bilateral knee pain with limited function. Clinical examination findings are consistent with bilateral knee osteoarthritis in the medial and patellofemoral compartments. She has failed to adequately respond to conservative treatment, including activity modification, nonsteroidal anti-inflammatory drugs, ice, and physical therapy. She has undergone prior Euflexxa injections, with reported pain relief and functional restoration. The peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Thus, the injectable medication Euflexxa is medically necessary for the treatment of this patient. 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 Upheld

Summary Reviewer 




The parent of an 11-year-old female enrollee has requested authorization and coverage for Nutropin AQ Nuspin. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees growth hormone deficiency. The physician reviewer found the requested medication is not medically necessary for treatment of the patients medical condition. There is insufficient medical information in the submitted material to support medical necessity of GH treatment. If the patients diagnosis is intrauterine growth retardation with failure to catch up in height by age three, then data on birth weight and height, as well as a longitudinal growth chart from infancy until the start date of GH therapy should be provided. Based on the growth chart included for review, the patients height was within normal limits for age at age seven years from the 25th to 50th percentile. Thus, there is a lack of evidence that she had short stature warranting GH treatment at that time, although it is unclear if GH was started prior to that time and if there was a prior fall-off in growth. Additional information documenting abnormal results on provocative GH testing, pre-treatment height and weight, complete longitudinal growth curve dating back to the time before GH therapy was initiated, pre-treatment insulin-like growth factor-1 (IGF-1) level  and results of other tests to rule out systemic causes of poor growth, were not provided to support the resumption of GH. As such, Nutropin AQ Nuspin has not been established as medically necessary for treatment of the patients medical condition. 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 49-year-old male enrollee has requested reimbursement for a positron emission tomography (PET) scan performed on 6/30/17. 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 in general, PET/CT is useful for staging a known malignancy. If indeed the final pathology was a tumor of renal origin, it is not clear the reason such a tumor was not seen on conventional imaging which would usually have been the case. There is a lack of support for the services at issue in this clinical setting. 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 49-year-old male enrollee has requested reimbursement for a positron emission tomography (PET) scan performed on 6/30/17. 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 very limited clinical information has been submitted concerning this patient. For some reason, a CT scan was obtained which demonstrated what was described as bulky adenopathy in the retroperitoneum, mesentery, and supraclavicular regions.  Lymphadenopathy is a common clinical presentation, and the first role of the provider is to determine whether this represents a significant systemic disease or whether the lymphadenopathy is likely due to a local inflammatory (and likely self-limited) reaction.  But when one has evidence of multisite bulky adenopathy, it can be assumed that this represents a significant illness. The next step is to differentiate between benign and malignant processes. In this patients case, considering the likely diagnosis of lymphoma, his providers proceeded with a bone marrow aspiration which was negative.  One critical issue is to decide on a node to biopsy that is both accessible as well as likely demonstrating an answer. It is in this situation where PET scanning is the most optimal next step.  By demonstrating metabolic activity, the provider can safely pick the most suspicious node to sample. In this case, obtaining a PET/CT scan was warranted, and is the typical common means to proceed in patients with this presentation. In sum, PET scan performed on 6/30/17 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 3

A 49-year-old male enrollee has requested reimbursement for a positron emission tomography (PET) scan performed on 6/30/17. 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 with the limited information that was provided, it seems that patient was found to have retroperitoneal lymphadenopathy, for which he underwent CT-guided bone marrow biopsy and then PET scan. Assuming that the cause of lymphadenopathy is unknown, CT-guided tissue sampling for bone marrow would be a standard approach. Also, to find out the extent of lymphadenopathy in the remaining body parts such as neck, chest, abdomen and pelvis, PET was also indicated. Thus, PET scan performed on 6/30/17 was 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 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.